Page 29 - TSAB Adult B FINAL (1)

This document was classified as: OFFICIAL

 Be proportionate according to the scale and level of complexity of the issues being examined;

 Be led by individuals who are independent of the case under review and of the organisations whose
actions are being reviewed;

 Ensure professionals are involved fully in reviews and invited to contribute their perspectives without
fear of being blamed for actions they took in good faith;

 Ensure families are invited to contribute to reviews. They should understand how they are going to be
involved and their expectations should be managed appropriately and sensitively.

 Focus on learning and not blame, recognising the complexity of circumstances professionals were
working within;

 Develop an understanding of who did what and the underlying reasons that led individuals and
organisations to act as they did;
 Seek to understand practice from the viewpoint of the individuals and organisations involved at the
time and identify why things happened;

 Be inclusive of all organisations involved with the adult and their family and ensure information is
gathered from frontline practitioners involved in the case;

 Include individual organisational information from Internal Management Reviews / Reports /
Chronologies and contribution to panels;

 Make use of relevant research and case evidence to inform the findings of the review;

 Identify what actions are required to develop practice;

 Include the publication of a SAR Report (or executive summary);

 Lead to sustained improvements in practice and have a positive impact on the outcomes for adults.

2. Case Summary

Josh was a young man in his late twenties who was homeless and had diabetes. He had taken multiple
overdoses of his insulin which has resulted in a number of admissions to hospital due to self-neglect of
his diabetes and misuse of medication. The taking of too much insulin (or not enough) leads to life
threatening emergencies. As a result of a significant overdose of insulin, Josh suffered a permanent
and life changing brain injury and it was believed that he was likely to have additional care and
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support needs for the rest of his life. Josh, however passed away unexpectedly in hospital on 2
January 2019.

3. Decision to hold a Learning Lessons Review

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The Safeguarding Adults Review Sub Group of the Safeguarding Adults Board met on 12 November
2018 and following the gathering of more information and the death of Josh, a further meeting on
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23 January 2019 agreed that the criteria for a Safeguarding Adults Review were met and made a
recommendation to the TSAB Independent Chair. The Independent Chair endorsed this decision. It is

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