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Adult D was in his early sixties, had a long-term partner and had two children from a previous marriage.

Adult D had ongoing physical health problems which led to a decline in his mental health resulting in admissions to and between hospitals where he sadly died of natural causes.

This Learning Lessons Review looks at how services worked together to support Adult D and specifically considers how services responded to the following key issues in Adult D’s life:

  • Self-Neglect
  • Application of the Mental Health Act
  • Mis-diagnosis of terminal illness
  • Safeguarding
  • Housing
  • Transfers between hospitals.

Adult D’s partner was consulted throughout the review and learning was also gained around support for carers.

This Learning Lessons Review considered 4 themes and identified 19 points for stronger practice. Please read the full report here:
https://www.tsab.org.uk/professionals/safeguarding-adult-review-sar-reports/