A SAR takes place where an adult with needs for care and support died or experienced abuse or neglect, and there are concerns about how agencies worked together to protect them.

Stephen, sadly died in hospital in February 2024, following a period experiencing self-neglect.  This review builds on a thematic self neglect SAR published in 2025, involving six individuals who had died in circumstances of self-neglect.

Learning from Stephen's experiences will inform system learning in respect of self-neglect to improve outcomes for indivdiuals.  

The Safeguarding Adult Review report is published today, you can read the full report here.

“Safeguarding Adult Boards (SABs) across the Country have a duty to commission independent reviews into cases and events which have occurred, where we think services may have worked differently to reduce the risk or prevented harm to individuals.

All of these events are distressing and tragic for families and friends, but also for those professionals involved. This is very evident within the case for Stephen.

The SAB itself is an independent body made up of statutory representatives from Health, Social Care and the Police, as well as other supporting services. It is chaired by me as an Independent Chair, and the Safeguarding Adult Reviews (SARs) that we commission, are run by an Independent Reviewer. In this way, as well as having the benefit of hindsight, we utilise expertise out with the SAB and agencies represented, which is not hindered by any relationship to individuals or organisations.

In this case the review highlighted the challenges that Stephen faced, and everyone that was trying to help and support him. The findings and recommendations of the review will be incorporated into an action plan, to support services in their continued work, when they are trying to assist, adults facing similar challenges.  Unfortunately, there is never a single answer. The complexities of individual lives, and the timing of events within people’s lives lead to a myriad of issues, difficulties, and consequences. We can however improve our joint working, and learning from these events, so that collectively we may be able to address such complicated scenarios presented within people’s lives.

The report itself recognises the commitment that both family and the professionals involved in trying to help Stephen, it also recognises the trauma that was felt by all. One of the outputs from the review will be to strengthen agencies support for families and practitioners through such tragic circumstances, and afterwards.

My thoughts are with Stephen’s family, and with the practitioners who worked to support him, everyone worked so hard to prevent this incredibly sad outcome”

My sympathies,

Rob McCulloch Graham CSAB Independent Chair

Cumbria Safeguarding Adults Board invite Practitioners and Managers from across the system to attend this lunch & learn session which will focus on learning from the Stephen Safeguarding Adult Review (SAR).  

Suzy Braye, Independent SAR Reviewer will present the learning from this review.  

Details: Friday 17th July 2026, 2-3.30pm, via MS Teams.

To book your place click the link to the event page here.