"Cumbria Safeguarding Adults Board (CSAB) has published today a Safeguarding Adults Review (SAR) examining the circumstances leading up to the tragic death of a 33‑year‑old woman, referred to as Samantha to protect her identity. As the report states, the review was commissioned because there was “reasonable cause for concern about how services worked together to safeguard the adult who sadly died.”
A SAR is a statutory review carried out under the Care Act 2014 when an adult with care and support needs dies or is seriously harmed, and there are concerns about how agencies worked together. The purpose is not to apportion blame, but to understand what happened, identify learning, and improve future practice.
The review highlights Samantha’s long history of trauma, substance misuse, domestic abuse, and significant barriers to engagement with services. Despite involvement from multiple agencies, the report identifies missed opportunities for coordinated safeguarding responses, earlier recognition of coercive control, and more robust multi‑agency risk management.
Key Recommendations
- Strengthen professional understanding of coercive and controlling behaviour, including when perpetrated by informal carers.
- Improve recognition of care and support needs, ensuring safeguarding enquiries are initiated where required.
- Enhance multi‑agency safety planning, particularly during periods of reduced service capacity.
- Develop clearer guidance on the use of inherent jurisdiction and decision‑making where coercion, trauma or substance misuse may impair autonomy.
- Increase awareness of financial abuse and the roles of banks and the DWP in protecting vulnerable adults.
CSAB will now work with partners across Health, Social Care, Housing, Policing and wider system to ensure the learning from Samantha’s case is embedded, to reduce the risks of similar incidents.
We would like to express our sympathy to family and friends of Samantha.
Rob McCulloch-Graham, Independent Chair, Cumbria Safeguarding Adults Board"
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