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Safeguarding Adults Review: DD


DD was a young woman with a complex medical and social history. The Coroner found that her death was a result of mismanagement of her diabetes.

She was well known to a range of services and was regularly attending hospitals. She had less contact with her GP and had changed GP several times.

Although had been offered support from a range of agencies, she had engaged to varying degrees with them.

She had also experienced a series of traumatic events leading up to her death.

Safeguarding Adults Review

This case did not meet the thresholds and criteria for a full safeguarding adults review. However, a local learning review was carried out to ensure that lessons are learnt and practice improved.

DD’s case was connected with the death of Child K. Islington’s Children’s Safeguarding Partnership carried out a review of the death of Chid K and there is some overlap between the learning recommendations from both reviews.

Learning Points


Transition is an unsettling time for many young adults.

DD was well-known to children's services but when she became an adult some services stopped and others handed her case onto equivalent adult services. DD was familiar with and trusted some of the children's services agencies. After transition, she found it hard to adjust without the level of support she had been used to.

  • Does your service plan ahead collaboratively with other services for a young person's transition?
  • Does your service allow for an adjustment period and accommodate gradual transitions if needed?


A frequent attender is as much of a red flag as a dis-engager.

DD was both. In some settings, she frequently attended hospital but she shut other services out or rarely engaged, for example with her GP. Professionals should have exercised more curiosity about why DD was frequently readmitted to hospital shortly after having been discharged.

  • Does your service monitor repeat/frequent attenders as well as disengagers?
  • Does your service explore the reasons why someone is not engaging? 
  • Do your risk assessments reflect disengagement or high intense use of your service?


Communication lapses can have serious outcomes.

In DD's case, there were several recording and reporting lapses, which meant that professionals working with DD did not have relevant information on which to base risk assessments and decisions about her care and support.

  • Does your service have up-to-date recording systems? 
  • Does your service routinely record hospital admissions and discharges? 
  • Does your service share information with those who have a need to know, such as GPs? 
  • Is your service knowledgeable about the interface between safeguarding and data protection laws?

Mental capacity

Even if a person is found to have mental capacity, they may still have vulnerabilities. 

DD, although assessed by many professionals as having the mental capacity to make decisions for herself, was very vulnerable and at risk of harm. She may have benefited from psychologically-informed approaches.

  • Is your service's definition of a 'vulnerable adult' too narrow?
  • Does your service offer staff training and mentoring around trauma- informed approaches, motivational practice and reflective supervision?


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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