Safeguarding Adults Review: Gertrude


Gertrude was of Caribbean heritage and Roman Catholic. She was 66 years old when she died in January 2021. She was described by her daughter as powerful, formidable, loving caring, resilient, stoical, and thoughtful.

Gertrude had multiple health problems, type 2 diabetes and mental health needs. She had experienced significant trauma in her life. Although she had insight into her situation, she often postponed medical appointments which led to her being discharged from services due to non-attendance. Also, her social landlords were unable to access her property for checks and repairs.

Gertrude was admitted to hospital in a severe diabetic coma in December 2020 due to diabetic mismanagement. A safeguarding concern was raised about the diabetic mismanagement and hoarding in her home. Gertrude acquired asymptomatic Covid while in hospital and was discharged home to be cared for by her daughter.

Telephone contact at home indicated that Gertrude’s health was fluctuating and in the final call, Gertrude was reported as disoriented. Gertrude died at home two weeks after her discharge from hospital.


This case met the criteria for a Safeguarding Adults Review (SAR) and a multi-agency reflective workshop methodology was adopted.

Learning Point #1

There was a lack of professional curiosity particularly about Gertrude’s situation. Professionals did not appear to consider whether Gertrude’s daughter was hindering access or whether she was doing what Gertrude asked.

  • Does your service model, encourage and develop professional curiosity in staff?
  • Is the importance of professional curiosity included in your safeguarding adults training for staff?

Learning Point #2

Gertrude was discharged from hospital into a severely cluttered home and the GP was not informed that safeguarding concerns had been raised. The extent of Gertrude’s tendency to disengage was not communicated to other professionals.

  • Does your service have robust processes in place for sharing information about service users? 
  • Do staff understand the potentially serious consequences of failing to share information about risks, such as hoarding and other safeguarding risks?

Learning Point #3

Gertrude’s daughter was not offered a carer’s assessment despite being known to be caring for her mum and indications she was having some difficulties in this role.

  • Does your service have processes in place to identify carers routinely? 
  • Do your staff know how and where to refer carers for a statutory carer’s assessment?  
  • Does your service adopt a ‘think family’ approach to all patients/service users?

Learning Point #4

Gertrude’s home was severely cluttered (clutter level 9).  The safeguarding concern was closed and professionals had not made use of the Hoarding Panel or Islington Multi-agency Hoarding Protocol.

  • Are staff in your service aware of the Islington Hoarding Panel and how to make a referral?
  • Do staff in your service know how to escalate concerns about someone’s safety and well-being?
  • Have your staff had safeguarding adults training and refresher training?


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