Plymouth Safeguarding Adults Board publishes Serious Case Review


Plymouth Safeguarding Adults Board has published the Serious Case Review into V.

Plymouth Safeguarding Adults Board has published the Serious Case Review into ‘V’ and you can access the full report here.

Carole Burgoyne, Vice Chair of the Plymouth Safeguarding Adult Board said: “First of all, we want to extend our sincere condolences to the family of V for their sad loss.

“We would also like to apologise for the length of time it has taken to get to this stage. It is a very complex case with a number of agencies involved and there have been a vast number of issues that have needed to be resolved before the serious case review could be published.

“The Plymouth Safeguarding Adults Board has been working with all the organisations involved to learn lessons from this tragic incident. Clearly a number of things went wrong over a period of time and V was failed by a number of services, so it is essential that we do all we can to help local services improve.

“The publication of the Serious Case Review, following the inquest in 2016, gives us some definitive answers and makes a number of recommendations of how services can improve and work together more closely.

“All the organisations involved have made changes to improve their processes and are making efforts to work more closely together. There has been progress in a number of areas, but of course there is no room for complacency and we strive for continuous improvement.

“In addition, there are a number of changes – both organisational and systemic – that should pave the way for better joint working, for example the integration of health and adult social care into one team.

“The SCR has implications for a range of services from the health service and police to adult social care and housing, and it is essential that people working in all of those areas learn from this tragic case.”

Changes made as a result of this case

All agencies involved have carried out internal investigations and made changes in response to this case, including:

  • A dedicated telephone line has been set up for all Mental Health Act assessment requests to the Daytime Adult Mental Health Practitioner team from other health and care professionals
  • Increase of staffing levels to Police Control, and auto-divert so that if a call to Exeter goes unanswered it will divert to Plymouth
  • Wider training for Police call handlers on vulnerable adults and safeguarding
  • South Western Ambulance Service is providing training and ensuring that all frontline and control room staff use the most clear, concise and appropriate language to ensure as far as possible that information is not misinterpreted
  • Local housing providers have improved their training of staff on safeguarding and improved staff awareness of vulnerable adults
  • The Local Medical Committee has circulated the Accessible Information Standard to all GPs to ensure that people with a disability or sensory loss receive information they can access and understand
  • Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG) has written to community pharmacies to give guidance highlighting best practice for when vulnerable patients are not collecting prescriptions
  • Plymouth Community Healthcare has improved its processes so that Care Coordinators request follow ups for patients, and where a patient does not attend an appointment, more follow ups are put in place
  • Plymouth City Council has reviewed the existing Vulnerable Adult Risk Management policy guidance and shared this with Safeguarding Adults Board partners.