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.