X SAR April 2017

Briefing X SAR FINAL 2017 Published April 2017


Introduction from Graham Bartlett, Independent Chair of Brighton & Hove Safeguarding Adults Board

I commissioned a Safeguarding Adult Review (SAR) following the death in December 2014 of ‘X’, a homeless individual in Brighton & Hove.  

As outlined in the 2014 Care Act, a Safeguarding Adults Review is held when an adult in the local authority area dies, as a result of abuse or neglect, whether known or suspected, and there is a concern that partner agencies could have worked more effectively to protect the adult.

At the time of their death X was in contact with and / or known to a number of local services in Brighton & Hove. This review has looked to establish whether there are lessons that need to be learnt in order to better support people in the city experiencing homelessness.

The review notes X’s mental health problems, learning difficulty and history of violent offending, and acknowledges that X was a very difficult and potentially dangerous person for support staff to engage with.

It concludes that a range of services were in place to address X’s needs, and that they had the potential to join together in a coordinated and purposeful way.

However, the absence of agreement about X’s mental health needs – and X’s unwillingness to engage with mental health services – acted as a barrier to such work.

While individual agency procedures were followed, these did lack an individual ‘person-centred’ approach. The exception to this was that staff from the community and voluntary sector showed greater flexibility in their dealings with X.

The Safeguarding Adults Review Subgroup is currently monitoring progress against a multi-agency action plan devised following the review.

The full report can be read here: Safeguarding Adult Review – Final Publication April 2017


There is a range of safeguarding training available on the Learning Gateway.  After reading the Briefing you may want to consider the following courses:

Or you may want to attend:  Safeguarding Adults – Basic Awareness or Mental Capacity Act Briefing