Cumbria Safeguarding Adults Board have today published a SAR relating to a young woman who, for the purpose of the review will be referred to as Donna.  

Donna moved between two areas and therefore this SAR identified important learning for both Cumbria Safeguarding Adults Board and Kirklees Safeguarding Adults Board. The implementation of the learning from this review will be jointly overseen by both partnerships.

Donna was 23 years old when she sadly died in December 2022.  

A SAR takes place where there is reasonable concern about how the Safeguarding Adults Board or members of it worked together to safeguard the adult, the adult has died, and the SAB knows or suspects the death resulted from abuse or neglect.

The SAR learning report highlights the learning from this sad case, you can read the Learning Report here. 

Donna experienced periods of abuse during her life, the Learning Report provides some detail of this and context for the learning identified.  It is noted that some of the detail may be difficult to read, practitioners should seek support if/as necessary.

Cumbria Safeguarding Adults Board will work in collaboration with Kirklees Safeguarding Adults Board to ensure that learning is disseminated and actions are taken to respond to the recommendations the report makes.

First and foremost I would wish to express my condolences to everyone who knew Donna and the loss they will have suffered through this tragedy. In response to such incidences, the Cumbria Safeguarding Adults Board works with all relevant agencies and organisations, to see if there is anything that individually, or collectively could have been done to reduce the risk of these awful events taking place.

The Board does this through commissioning a Safeguarding Adult Review (SAR). Such reviews identify areas of learning for services which support the protection of vulnerable people. The SAR that has been undertaken regarding Donna is now being published, within this there are a number of recommendations which will now be followed up by the agencies involved.  The aim and the aim of the partnership is to reduce the risk and likelihood of such events repeating themselves for others.

The Board will continue to work with our partners to address the aspects highlighted within this SAR, and we commit to work with all other agencies who can take a proactive role in reducing such risk in the future.

Again I would wish to offer to all who knew Donna, from myself and from the Board, and the partnership of agencies, our sincerest condolences, on the loss of such a young life.

Rob McCulloch-Graham

Independent Chair Cumbria & Kirklees Safeguarding Adults Board

Thursday 7th November, 12:00 - 13:30, via Microsoft Teams

Practitioners are invited to attend a learning session which will provide an overview of the key themes and lessons learned following the SAR, Donna.  The session will be faciliated by Mick Haggar, Independent Reviewer for the SAR. 

Practitioners from both Cumbria and Kirklees are invited to attend the lunch and learn session to find out more about the learning the SAR identified. 

To reserve a free place, please click here.