A Safeguarding Adults Board is undertaking a Safeguarding Adults Review. The review involves a 74-year-old female with a recent diagnosis of Vascular and Alzheimer’s dementias. She was under the care of the Older Adults Community Mental health Team (OACMHT) in the area.

SP was last seen by her friend on 6 September 2023, and reported as a missing person a few days later. SP’s body was found on 23 September 2023 in a wooded area. The Police have confirmed that there is no evidence of foul play. At time of informing the SAB, the cause of death had not yet been disclosed as toxicology results were pending.

Key themes and scope of the review 

The following areas for review have been highlighted during the process of determining whether a SILP should be commissioned:

1. To explore ways to maintain effective multi-agency working between organisation to ensure that professional curiosity is exercised in situations where there may be missed opportunities or concerns around SP.
2. To gain an understanding around SP’s presentation, namely issues which may help or hinder professional recognition of and response to self-neglect and mental capacity.
3. To explore how the principles of the Mental Capacity Act were considered.
4. To determine how professionals involved might have done things differently to reduce risks to SP.
5. To explore local Missing Persons practice, taking into consideration the Herbert Protocol, to understand the escalation process for those identified as being most vulnerable go missing. 
6. To explore any gaps in current multi-agency support systems to assist professionals to fully support vulnerable people who are self-neglecting.
7. To explore the effectiveness of a section 42 referral for people who self-neglect.
8. Making Safeguarding Personal – how this is interpreted by professionals working alongside multi-agencies.
9. What was the care providers escalation process for reporting missing people, and why was the care package breaking down.

Experience required for the Review

• Experience working at a senior level within Health and/or Adult Social Care, and good safeguarding knowledge including knowledge of the Care Act 2014, Mental Capacity Act, and any other legislation relevant to the themes of this review.
• Experience of undertaking SARs, or similar reviews.
• A good understanding of the review subject area as outlined in the case overview above.