Plymouth Safeguarding Adults Board publishes review

Plymouth’s Safeguarding Adults Board has published a review into the circumstances surrounding the death of Ruth Mitchell.

Carole Burgoyne, vice chair of the Plymouth Safeguarding Adult Board said: “We would like to formally offer our condolences to the family of Ruth Mitchell.

“While we acknowledge that nothing will make up for their devastating loss, we hope that Ruth’s family will find some solace in the fact improvements are being made to ensure organisations work together in a way which is designed to prevent such tragic circumstances reoccurring.”

The Safeguarding Adult Board (SAB) is responsible for commissioning Safeguarding Adult Reviews under the requirements of the Care Act 2014. The purpose of a Safeguarding Adult Review is to establish if partner agencies could have worked more effectively to protect the person in their care and to promote effective learning and improvement actions to prevent future deaths or serious harm occurring again.

Carole said: “This particular case highlights the importance of agencies sharing information and for staff to be confident in working together with each other to make sure that those who most need our help receive get it.

“All the organisations involved have made changes to improve their processes and are making efforts to work more closely together.”

Since 2015, the city has had integrated health and social care services in order that they are more centred around patients and service users.

There is now a Plymouth multi-agency adult safeguarding risk management, self-neglect and hoarding policy and guidance, that is being shared among staff from all health and social care organisations across the city and beyond.

“Plymouth has set up the creative solutions forum, specifically designed to provide a more tailored package for people with some very complex needs, we recognise that there are people who desperately need help and support, but because of their mental illness, may not be so willing to engage with services”.

This forum recognises that one single agency or organisation may not have all the answers or support available and the standard social work or health care response does not fit the need of the person involved.

The report’s recommendations include:

• Agencies must develop processes to share information to prevent harm. If information is shared it should be clear, using words understood by all agencies and avoiding statements that lead to assumptions and labels.

• All agencies can call a risk management meeting and work out a plan together to work with the adult. If one agency will not engage with this process, the adult safeguarding team can provide advice and support.

• More clarity about the individual’s consent and what exactly can and cannot be shared among agencies. Certain information may need to be shared in order to reduce risk.

• The police vulnerability screening tool system should be reviewed with agencies looking at how information is stored and reacted, in order to achieve consistency.
• Good practices developed by Plymouth Community Homes must be demonstrated by all housing providers.

• Improved internal systems to record concerns, as well as external information sharing, are needed. If referrals are made they must be followed up. Agency records need to be made close to the time the adult is seen and then clear personal, physical and environmental descriptions to assist the next agency or worker to understand if deterioration has occurred.

• A multi-agency self-neglect risk assessment and management recording template is needed to ensure that self-neglect is captured and understood consistently across all agencies.

• All mental health professionals to receive substance misuse training and closer working with substance dependency services.

• Agencies must risk assess organisational change and draw up plans to mitigate the risk of service quality diminishing for service users during these times.

• Clinical Commissioning Group and Public Health commissioners must work with Primary Care Services, Public Health, health and care providers to consider how the physical, as well as mental, wellbeing of people with severe mental ill health is supported.

To read the full report visit

The overarching purpose of a SAB is to help and safeguard adults with care and support needs. It does this by:
• Assuring itself that local safeguarding arrangements are in place as defined by the Care Act 2014 and statutory guidance
• Assuring itself that safeguarding practice is person-centred and outcome-focused
• Working collaboratively to prevent abuse and neglect where possible
• Ensuring agencies and individuals give timely and proportionate responses when abuse or neglect have occurred
• Assuring itself that safeguarding practice is continuously improving and enhancing the quality of life of adults in its area.