In Sept 2018, Newham, Islington, City and Hackney & Lambeth’s Safeguarding Adults Boards undertook a combined review to understand the barriers that prevented partner agencies protecting ‘Yi’, an adult at risk of chronic homelessness, from serious harm. Chronic homelessness is typified by prolonged periods of homelessness, including rough sleeping, together with physical, mental ill health and/or substance misuse.

The review, led by independent reviewer Fiona Bateman, identified learning and recommendations for both local SABs and wider learning for the London Safeguarding Adults Board. This included:

• improving knowledge within the workforce of the legislative framework for health, housing and social care
• creating greater understanding of the role of the voluntary and community sectors
• ensuring Policy/guidance directly addresses common barriers to effective interventions and provides mechanisms for overcoming these

The full report, including a statement from the SAB Chairs, can be found on the LSAB website.

Martin was a 51 year old man who at the time of his death had been living in squalid conditions and was physically frail. The Lambeth Safeguarding Adults Board commissioned an independent Safeguarding Adults Review (SAR) to explore the learning from the circumstances of Martin’s death.

This SAR raised important issues around the link with mental capacity and self-neglect. This included key learning around the need for mental capacity assessments to explore more than what a person says they can do; “a mental capacity assessment must also explore whether the person can put these verbal claims into some sort of meaningful action, and if they cannot whether they are able to use and weigh this information to make decisions about other options” (7.1 Learning Point 1). Furthermore, there is a need for better understanding of the interaction between self-neglecting behaviour and risk to the person’s vital interest, and the need for a deeper level of professional curiosity. (7.3 Learning Point 6).

The review also highlighted issues with multi-agency communication and escalation processes. This included learning around referral mechanisms and the processes in place to respond to imminent risk (7.2 Learning Point 5).

The Lambeth Safeguarding Adults Board has agreed all recommendations from this review, and this will now be built in to a targeted action plan. This will include the development of multi-agency self-neglect policies and procedures, and communication pathways which allow for frontline practitioners to initiate urgency multi-agency conversations with all agencies involved.

The full report by independent reviewer Kate Spreadbury can be found on the LSAB website.

Mr E died in a house fire in March 2017. Mr E had had periodic contact with mental health services from 1990 up until his death, with support generally focused on the issues of anxiety and depression. Lambeth’s Substance Misuse Team had also offered information and support to help Mr E access services which could help with his drinking.

A Safeguarding Adults Review was undertaken and this found that a considerable amount of work had been done by the agencies involved with Mr E and that repeated attempts were made to engage him and to encourage him to accept support. Lambeth Fire Brigade’s report indicated that the fire started most likely via an unextinguished cigarette. It is most likely that Mr E’s ability to react may have been limited by intake of alcohol and other substances. As such, there was no link established between Mr E’s death and lack of action by those involved with him.

Nonetheless, the review process identified a number of important recommendations that have been developed in to an action plan that will be monitored by the Lambeth Safeguarding Adults Board.

The recommendations included improving communication pathways by having an escalation procedure and the development of a multi-agency self-neglect policy which would set out how agencies can raise persons of concern, and facilitate a multiagency approach, where the threshold for a safeguarding enquiry is not met.

The Executive Summary for SAR E can be found on our website.