Safeguarding Adults Review: BB and CC


Ms BB and Ms CC had lived together for more than 40 years and were described by those close to them as having been caring, clean and tidy people.

In 2015, Ms BB and Ms CC's care and support needs increased and they were both diagnosed with probable dementia. They started receiving 24 hour care at their home following Ms BB's discharge from hospital in August 2015. But Ms BB was reluctant to accept care and they both frequently obstructed carers’ access.

A month later, Ms BB was admitted to hospital with a urinary tract infection, malnutrition, dehydration and a badly infected pressure ulcer. She died shortly after admission.

Questions were raised about the circumstances around Ms BB’s death and the neglected state in which she arrived at hospital, given that she was supposed to be receiving 24 hour care at home.

Safeguarding Adults Review

The Islington Safeguarding Adult’s Board decided to conduct a review to ensure that lessons were learned and practice improved.

The review looked at the period from May 2013 until Ms BB’s death in October 2015 and made many recommendations about how professionals could have worked better together.

The services involved in the review all worked to action plans to implement the recommendations.

Learning Points

Pressure ulcers

Pressure ulcers can be fatal, but are often preventable.

Many of the professionals involved in Ms BB's care failed to spot the early warning signs that Ms BB was developing a pressure ulcer. They also failed to take action when she was clearly losing weight and when the pressure ulcer was deteriorating.

Can the staff in your service identify early signs of pressure ulcers?

Does your service know how and when to escalate concerns about skin integrity?

Do your staff understand the links between pressure ulcers, malnutrition, continence and mobility?

‘Unwise’ decisions

Repeated 'unwise decisions' should prompt further consideration of mental capacity.

Both Ms BB and Ms CC refused and obstructed care, without fully appreciating the risks to their health and wellbeing. As they had both been diagnosed with probable dementia, their mental capacity to refuse care should have been explored further.

  • Do the staff in your service have a clear understanding about balancing choice and unwise decisions against the duty to promote well-being of adults with care and support needs under the Care Act?

Risk Assessments

Robust risk assessment and personalisation are central to good practice.

In Ms BB's case, risk assessments were not holistic enough and communication between the professionals about how to manage those risks was poor.

Professionals failed to take the views of Ms BB and CC and their families into account. This meant that the approach to Ms BB's and Ms CC's care and support needs was not personalised.

  • Does your service routinely adopt a personalised approach?
  • Do your staff take the service user and family views and wishes into account?
  • Is risk assessment robust and embedded in your service?

Hospital discharge

Hospital discharges of adults with care and support needs requires careful planning and co- ordination between key professionals.

Ms BB was discharged from hospital without a proper package of care and support being in place. The hospital being out-of- borough made the discharge process more complex.

  • Is your service involved in hospital discharge planning? If so, do you have processes in place for ensuring quality of care continues at home after a hospital discharge?
  • Is there more your service could do to ensure that care plans are updated on discharge from hospital?


If you are worried about someone who may be at risk of abuse or harm please contact the Access and Advice Team on 020 7527 2299 or complete the online safeguarding concern form