Published on behalf of the Torbay and Devon Safeguarding Adults Partnership
The Torbay and Devon Safeguarding Adults Partnership (TDSAP) has published a ‘Thematic’ Safeguarding Adults Review (SAR) into the death of three men who died as a result of self-harm and suicide during the pandemic.
Adult C aged 59 died on 4th September 2020; Adult N, aged 53, died on 11th September 2020; and Adult B, aged 46 died on 19th January 2021.
Whilst the three men had different individual circumstances, there were parallel themes in regard to their mental health, and their associated difficulties were complex, with escalating distress and requests for help.
The aim of this SAR was not to re-investigate, but to evaluate and explain professional practice, highlighting challenges, system problems and constraints to practitioner efforts to safeguard adults and interagency working during the pandemic.
Additionally, within the analysis and findings, the report provides insight into improving responses for all individuals in similar situations.
The criteria for conducting such a review is laid out in the Care Act 2014.
A Safeguarding Adults Board is required to commission a Safeguarding Adults Review (SAR) where an adult with needs for care and support has died, and the death is thought to be a result of abuse or neglect, including self-neglect.
The Partnership concluded that the circumstances in each case met the mandatory criteria.
The review was comprehensive and conducted through an open and transparent process including interviews with professionals, partner agencies and family members.
Paul Northcott, the Independent Chair of the Torbay and Devon Safeguarding Adults Partnership, said:
“The care and support of the three men occurred during the unforeseen and unprecedented global event of the pandemic and the aim of this review was to explain professional practice, highlight challenges, system problems and constraints to practitioner efforts during this time.
“There is no doubt that the pandemic had an impact on the experience and level of service delivery at the time when the men’s mental health was deteriorating and they were experiencing ongoing distress.
“As a result of this review 10 recommendations have been made which have been accepted by the Partnership.
“These recommendations aim to provide governance and instil confidence by means of assurance that service development and changes made in mental health services over the last few years has addressed the identified system issues and gaps.
“The TDSAP has developed an action plan with time scales that are realistic and achievable with partner agencies.
“Both the Partnership and I would like to thank the individuals’ families for their assistance and their contributions in the compiling of this report.
“The deaths of all three men have had a huge impact on their lives, and we would like to express our sympathies and sincerest condolences.”
The full report is published on the Torbay and Devon Safeguarding Adults Partnership website.