Page 29 - Adult C Overview Report - FINAL

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the date of her death, it was her partner who called an ambulance; her ex father in law was also
present. They were originally arrested for the murder of Adult C, but her death was later deemed
to be from physical health causes. An inquest is open and ongoing.

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 15 May
2019. It was agreed that the criteria for a Safeguarding Adults Review were not met and made a
recommendation to the TSAB Independent Chair that there was likely to be learning in the way
that agencies worked together to safeguard Adult C and recommended a Learning Lessons
Review. The Independent Chair endorsed this decision.

4. Scope

The review will cover a period six months prior to death. Key background information will also
form part of the review that will inform the more contemporary elements of Adult C’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 Adult C’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. Mental Capacity

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