Review Opportunities

North Yorkshire Safeguarding Adults Board

The North Yorkshire Safeguarding Adult Board is seeking to identify an independent reviewer to complete a newly commissioned Safeguarding Adult Review (SAR).

Case Overview

‘Amber’ was a woman with extensive and complex health needs, including Type 1 diabetes. She also had a PEG-J feeding tube and was frequently admitted to hospital for diabetic ketoacidosis and other complications. She was mostly independent in managing her medical devices and daily activities, though she relied on district nurses and specialist teams for periodic support.

Amber experienced challenges with personal and family relationships. She had multiple friends who provided support, though some relationships were exploitative, involving financial abuse and neglect of her dog, whose death in 2024 impacted her greatly. Her son was taken into care, and she was estranged from her father and sister. She had a history of multiple contacts with mental health services including crisis teams, psychiatric liaison, and was prescribed medicine to help her to manage her mental health challenged. Her mental health was further impacted by significant trauma, including childhood abuse, sexual assaults, bereavement following her mother’s death, and social isolation, which she managed through self-harming behaviours.  Despite these challenges, Amber demonstrated insight into her health needs and engaged with services when able, though her engagement was often inconsistent.

Amber lived alone. Amber’s tenancy with Together Housing Association began in 2006 and was marked by ongoing concerns about hoarding, poor property conditions, fire safety risks, and vulnerability to exploitation. She frequently stored medical supplies and personal items in communal areas, and neighbours reported issues such as dog fouling, noise disturbances, and abusive behaviour.

Multi-agency efforts were made to support Amber over the years, including referrals to Adult Social Care, Living Well, the Fire Service, RSPCA, and mental health services. Despite these interventions, Amber’s home conditions often deteriorated, and she sometimes declined access to support services.

Amber was found deceased in her home in May 2025. The scene indicated self-neglect, with clutter and poor living conditions.

Review themes

Key areas of focus are:

1. Professional Curiosity
2. Missed Safeguarding Opportunities
3. Hospital Discharge Planning
4. Escalation and Oversight
5. Hoarding Protocols
6. Risk Assessment and Supervision

How to apply

Please submit the following:

• a covering letter
• Your CV 
• Provide contact details for two references
• Will need to confirm their independence by confirming there is no conflict of interest with the review.

Please express an initial interest in this opportunity by clicking here to send us a whats app message. You can also ask any questions and clarifications using the link as well. 

The deadline for receipt of your application is midnight 21st January.

Documents in support of your application will be received via our reviews inbox: [email protected]