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Safeguarding Adults Review: AA


Mr AA was an 84 year old man, who had previously been in the armed services.

On his retirement, he lodged with a family and became very close to them, so much so that he regarded them as his next of kin. When his care and support needs increased in 2008, he was placed in a care home in Islington.

In the first few months of 2013, Mr AA was admitted to hospital three times for pressure ulcer care, prompting concerns about the care home and about the hospital discharges. When Mr AA then died in June 2013, his next of kin raised several safeguarding concerns about the end of life care Mr AA had received in the care home and hospital.

Safeguarding Adults Review

The Islington Safeguarding Adults Board reviewed the case and decided to conduct a serious case review to ensure that lessons were learnt and practice improved.

This case pre-dates the introduction of the Care Act 2014. Despite the age of the case, some of the learning from this case remains relevant today.

The review looked at the period from January 2013 until Mr AA's death in June of that year. The review made recommendations for improvements and learning.

The services involved in the review all worked to action plans to implement the recommendations.

Learning Points

Pressure ulcers

Pressure ulcers can be fatal, but are often preventable

Many of the professionals involved in Mr AA's care failed to spot the early warning signs that Mr AA was developing a pressure ulcer. They also failed to identify

Mr AA's increasing care and support needs and to escalate to the appropriate professionals.

  • Can the staff in your service identify early signs of pressure ulcers? 
  • Do your staff understand the links between pressure ulcers, hydration, continence and mobility? 
  • Does your service know how/when to escalate concerns about whether a care home can still meet someone's needs?

Hospital discharge 

Hospital discharges of adults with care and support needs requires careful planning and co- ordination between key professionals.

Two of the three hospital discharges of Mr AA were done without proper planning and communication about his needs. For example, he was discharged without a pressure-relieving cushion being ordered.

  • Is your service involved in hospital discharge planning? If so, do you have processes in place for ensuring quality of care continues after a hospital discharge? 
  • How can your service ensure good communication between services on discharge from hospital?

Mental Capacity Act

The Mental Capacity Act (MCA) is as relevant for refusal of care as it is for end of life decisions.

Despite Mr AA's known dementia, the MCA was not used properly by staff and professionals to protect him when he refused necessary pressure ulcers care.

Formal mental capacity assessments weren't carried out for Do Not Attempt Resuscitation notices.

  • Does your service ensure front-line care staff and professionals have a good working knowledge of the Mental Capacity Act?
  • Do your staff know where to go for help or legal advice when they are not sure how to implement the Mental Capacity Act or make best interests decisions?

Involvement of close family and friends

Mr AA was estranged from his family, but he had close friends who knew him well because he had lived with them for many years before moving into the care home. Professionals failed to consult those friends in care planning, best interests decisions, safeguarding enquiries and mental capacity considerations.

  • Is your service aware of the making safeguarding personal approach? 
  • Do your staff routinely take family or friend views and wishes into account in mental capacity assessments and safeguarding enquiries?


If you are worried about someone who may be at risk of abuse or harm please contact the Access and Advice Team on 020 7527 2299 or email

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