Birmingham Safeguarding Adults Board publishes the Executive summary of the A2 Serious Case Review

The Birmingham Safeguarding Adults Board (BSAB) has today published the Executive Summary of a Serious Case Review undertaken in 2012. The review was held following the admission to hospital of an elderly man (referred to as A2 throughout the Executive Summary) where there were some longstanding concerns about possible self-neglect/neglect by others and possible financial abuse. A decision was taken to hold a Serious Case Review in December 2011.

Following admission to hospital in November 2011 the elderly man was assessed as needing nursing care. He was cared for in a nursing home prior to admission to a palliative care unit. He died in April 2012 as a result of longstanding health conditions.

The purpose of a Serious Case Review is broadly to establish whether there are lessons to be learned from the circumstances of a case and in particular about the way in which local professionals and agencies work together to safeguard vulnerable adults.

The BSAB take adult safeguarding very seriously and are willing to learn from cases in order to improve service delivery and practice to try to ensure that we protect the most vulnerable members of the community.

All of the agencies involved in this case participated fully with the review process.  The review highlights a number of areas for improvement in both multi-agency and single agency practice. These include issues relating to working with an individual who is reluctant to accept health and social care services, the understanding and use of the Mental Capacity Act 2005, the application of policy and procedures in relation to safeguarding adults, risk assessment / management and direct payments.

As a result of undertaking the Serious Case Review, Board members now have a multi-agency action plan and agencies will work on this to ensure improvements are made in the way we deliver services to those who may be at risk. The Board will monitor the implementation of this action plan and require assurance from member agencies that they have addressed both the multi-agency action plan and any individual agency action plans arising from the in-depth review of this case.

View the Executive Summary of the review (entitled A Serious Case Review in Respect of A2).


Alan Lotinga, Chair of the Birmingham Safeguarding Adults Board
25th April 2013

This article was posted in News.