Page 30 - TSAB Adult B FINAL (1)

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of note that it was the issue of self-neglect of his diabetes where the criteria are met for a SAR and not
the death in hospital for which the cause is not currently known.

4. Scope

The review will cover the period 01/03/18 and 21/09/18. This is the period that covers identification
of considerable numbers of contacts with agencies. Key background information will also form part of
the review that will inform the more contemporary elements of Josh’s journey.

5. Method

In determining the methodology to be used for this Learning Lessons Review the TSAB considered the
Care Act 2014 Statutory Guidance which states that the process for undertaking SARs should be
determined locally according to the specific circumstances of individual cases. No one model will be
applicable for all cases. The focus must be on what needs to happen to achieve understanding, remedial
action and, very often, answers for families and friends of adults who have died or been seriously
abused or neglected.

TSAB chose to use a methodology that engages frontline practitioners and their line managers. Agencies
are asked to review their own involvement and provide a report of their findings and learning. Those
who were involved, alongside the authors of the reviews will then be invited to engage in a Learning
and Reflection Workshop to review all of the material and identify key themes and learning. A Review
workshop will take place to review the first draft of the overview report.

6. Key Lines of Enquiry to be addressed

As well as broader analysis provided within the Agency Review Reports the following case specific key
lines of enquiry will be addressed.

6.1. Assessment

What assessment did your agency undertake of Josh’s holistic needs, inclusive of physical and mental
health? How robust was this? How did this inform care planning and interventions? Please provide
analysis of what assessment policies and frameworks were in use and identify any gaps in policy
and/or practice.

6.2. Multi Agency Working

What did your agency understand of the other agencies involved? What evidence is there regarding
multi agency coordination and sharing of risks, assessments and plans? Discuss this in terms of what
would be expected for multi-agency working in a case of this nature.

6.3. Responding to Crisis

How did your agency engage in responding to crisis points that Josh experienced? Were there any
specific multi agency plans and responses to manage risk of suicide or death by misadventure?

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