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The Surrey Safeguarding Adults Board has published its Serious Case Review into the death of Mrs A..

A statement from the board’s independent chair, Simon Turpitt, is below.

'This Review was commissioned by the Surrey Safeguarding Adults Board in order to ensure an independent view around the circumstances that led to the tragic death of Mrs A and to highlight the learning for those agencies involved.“The Surrey Safeguarding Adults Board will hold involved agencies and organisations to account to implement the recommendations made and will monitor the impact of the changes to ensure that the improvements recommended are acted upon so that others are protected in the future'.

“It is clear in this case that the legacy of child sexual abuse and its impact on Mrs A, whose brave action to testify against the perpetrators, drove her to a very vulnerable situation and certainly agencies have some key learnings from this.”

Simon Turpitt
Independent Chair of the Surrey Safeguarding Adults Board

'The Surrey Safeguarding Adults Board will hold involved agencies and organisations to account to implement the recommendations made and will monitor the impact of the changes to ensure that the improvements recommended are acted upon so that others are protected in the future'

Click here for the full SCR

Learning for Health Professionals includes improving our understanding of the meaning of vulnerability within adult safeguarding definitions

'Mrs A’s GP did not initially consider her to be a “vulnerable adult” within the terms of the government’s guidance on abuse, ”No Secrets” (DOH 2000) and did not consider making a referral under the Safeguarding Vulnerable Adults protocol. Surrey Police did come to see her as vulnerable in terms of her mental health and referred her to mental health services (using a 39/24 form) , but not through the adult safeguarding route.

' No Secrets” sets the threshold for a safeguarding intervention at the level of eligibility for a community care assessment, stated in these terms,

-anyone who may be in need of community care services by reason of mental or other disability, age or illness

-is or may be unable to take care of himself or herself, or unable to protect himself or herself against significant harm or exploitation.

Mrs A might therefore have been seen to fall within the definition set out in this guidance in that she was mentally unwell at least to a threshold

that would entitle her to seek assessment under the NHS and Community Care Act 1990 and could therefore have been seen as a vulnerable adult

under this provision.

Moreover, Surrey’s Safeguarding Adults policy does include victims of historic abuse within its definition of a “vulnerable adult”.

So, while Mrs A was not at risk of abuse as an adult , as a victim of historic sexual abuse she was vulnerable to being harmed by recalling these

abusive experiences and at risk of causing herself harm when the painful states she had experienced were reactivated as a result of giving evidence.

She should therefore have been offered appropriate care coordination and mental health support. A multi-agency and multi - disciplinary approach

was required and should have been provided either under the aegis of the CMHRS or within an Adult Safeguarding framework.'