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Case Studies

In addition to Safeguarding Adult Reviews the partnership will produce case studies to support reflective practice. Key learning points are in bold in the description.

Ryan – published May 2024

A case study sharing learning from an internal review by Reading Borough Council, following the death of a 44-year-old man, Ryan. Ryan died at home, the cause of death is unknown, Ryan was known to health and social care services in Berkshire. This learning briefing gives good practice guidance based on Ryan’s story regarding continuity of care.

RB – published May 2023

A case study sharing learning from an internal review in West Berkshire, following the death of a 70 year old lady, who died in hospital with pressure wounds acquired at home. Multiple care calls had been cancelled over a period of time.


Robert – published January 2023

A case study sharing learning from a safeguarding enquiry where the use of clinical terminology can sometimes lead to confusion for individuals and people supporting with them.

Peter – published September 21

A case study sharing learning from a single agency review in regards to how safeguarding concerns in relation to quality and suitability of care were managed.

Safeguarding looking back to see how to move forward in practice a primary care case – published May 21

The West of Berkshire Safeguarding Adults Partnership Board have  published a case study from a professional review in regards to X. This case study highlights the importance of seeing and talking directly to the person involved when working with remote consultations.

Nigel – Published May 21

The West of Berkshire Safeguarding Adults Partnership Board have published a case study from a professional review in regards to Nigel.

The professional review identified that agencies supporting Nigel worked in silos which made it difficult to identify and respond to his circumstances as self-neglect. Nigel was not presenting to agencies in a way that is identified as typical in someone who is self-neglecting and on face value Nigel appeared to be engaging with services. A multi-disciplinary approach in responding to the safeguarding concern raised would have been more appropriate and may have led to a better outcome for Nigel.  As each agency had different pieces of information which would have formed a more comprehensive picture on how Nigel was managing and engaging with services.

The case study details what each agency knew about Nigel individually, in chronological order, and how they responded in order to demonstrate what a multi-agency approach would have possibly identified.  Please take the time to consider this case and reflect, are there any individuals that that may benefit from a multi-agency response/discussion?

Practice Learning Notes from Safeguarding Adult Reviews

The Board have published the following practice learning notes from safeguarding adult reviews.

  • AdamInformation sharing, complex joint investigations
  • Aubrey Mental Capacity Act, Unwise Decisions, Recording, Pressure Care Management
  • Ben – Provider Concerns, Pressure Care Management, Mental Capacity Act
  • Carol – Advocacy, Risk Management, Self-neglect, Mental Capacity Act
  • Daniel – Court of Protection, Next of Kin, Processional Curiosity, Advocacy, Targeted Exploitation
  • Gemma – Pressure Care Management, Equipment
  • Graham – Making Safeguarding Personal, Advocacy, Safeguarding Procedures, Mental Capacity Act, Professional Curiosity/Challenge
  • Henry – Targeted Exploitation, Self-neglect, Court of Protection, Hoarding, Fire Risk Management
  • John – Lasting Power of Attorney, Direct Payments, Best Interest Decision Making
  • Louise – Direct Payments, Self-neglect, Mental Capacity
  • Margaret – Fire Risk Management, Multi-agency Response
  • Michelle – Transitions, Commissioning, Risk Management, Making Safeguarding Personal
  • P – Contractures, Pressure Care Management, Responding to Concerns
  • Paul – Domestic Abuse, Self-neglect, Carers, Safeguarding Practice
  • Pauline – Dementia, Mental Capacity Act, Managing Risk