Gateshead Safeguarding Adults Annual Report 2024/25

SAR Referrals 2024/25

Referral 1

In April 2024, a woman aged 44 sadly passed away. A coroner's inquest concluded that her death was the result of misadventure. She had relocated to the Gateshead area in October 2023, having previously engaged with services in the Durham area. Her family, including her children, reside in Yorkshire. She had a diagnosis of Emotionally Unstable Personality Disorder and had previously disclosed suicidal intentions to professionals.

In March 2024, a Safeguarding Concern was raised by the Northeast Ambulance Service (NEAS), highlighting issues including self-harm, alcohol dependency, self-neglect, and home invasion. The case progressed to a Section 42 enquiry in April 2024, and initial information gathering had commenced. Unfortunately, she passed away before her views and wishes could be obtained, and prior to the enquiry reaching the planning stage.

The case was reviewed by the SARCC Group to determine whether she had identified care and support needs under the Care Act in relation to her mental health and substance misuse. The group also considered the effectiveness of multi-agency safeguarding efforts, including cross-boundary working between Gateshead and Durham services, and whether information sharing practices impacted the ability of services to engage with and support her effectively.

While the case did not meet the threshold for a mandatory Safeguarding Adults Review (SAR), the group recommended its inclusion in a thematic analysis. This analysis will focus on cases involving alcohol misuse and mental health concerns where individuals did not present with care and support needs.

Referral 2 Adult K

Adult K was discharged from hospital in Durham and subsequently admitted to a care home in Gateshead. In July 2024, following concerns about significant harm experienced during his placement, a Safeguarding Adults Review (SAR) referral was submitted to the Gateshead Safeguarding Adults Board (GSAB) by the Safeguarding Co-ordinator who had overseen the Section 42 enquiries into the neglect and harm Adult K suffered.

According to Mosaic, Gateshead Council's social care management system, Adult K had eligible needs for care and support under the Care Act 2014. He was unable to meet these needs independently and required ongoing assistance. He was admitted to a care home in Birtley at the end of February 2024.

Adult K was also eligible for NHS podiatry services, and although a referral was made by the Community Nurse Practitioner and later escalated by the GP, no podiatry input was provided. There is evidence of poor communication between professionals, with no multi-disciplinary team (MDT) meetings held until the day Adult K was admitted to hospital.

Adult K was a known diabetic and had previously received podiatry care in Durham. This critical aspect of his health management was not picked up following his move to Gateshead. In April 2024, Adult K was admitted to hospital with an open wound and pressure damage to his foot, which progressed to a bone infection, ultimately resulting in the amputation of several toes.

Concerns were raised about the standard of care provided in the residential home. Adult K was described as being in a state of extreme poor hygiene and not receiving appropriate levels of care. It is likely that delays in making referrals and securing appropriate support contributed to the severity of his injury.

The SARCC group was asked to consider whether the injuries sustained by Adult K were the result of abuse and neglect, and whether agencies in Durham and Gateshead worked effectively together to safeguard him.

Based on the information provided in the SAR referral, there is reasonable cause for concern regarding the effectiveness of multi-agency working. This includes the care home, GP, podiatry services (Durham and Gateshead), and mental health services (Durham and Gateshead). The case met the criteria for a mandatory SAR.

An independent author was appointed to lead the review, and a practitioner workshop was held in March 2025. The final report and recommendations are scheduled for submission to the SARCC in June 2025, with a view to presenting them to the GSAB for final approval.

Referral 3 (Adult L)

Adult L passed away in April 2024 at the age of 38 from acute alcohol intoxication. GSAB received a referral for a SAR from the Safeguarding Coordinator then led the safeguarding investigations (under Section 42 of the Care Act) concerning time over the last 18 months before Adult L died.

In July 2024 the SARCC discussed the case and concluded that the case did not meet the criteria to progress to a statutory SAR as Adult L did not have identified care and support needs under the Care Act and there was no evidence that agencies had not worked together to safeguarding her.  There was evidence of self-neglect relating to alcohol use and due to the number of services and difficulties in working with Adult L it was agreed that a discretionary review should be undertaken to consider how agencies can work to support people with complex presentation and multiple risk factors.

After agreeing to move forward, representatives from the Gateshead GSAB, the Local Authority Safeguarding Team, Public Health, and Community Safety (Domestic Abuse) met to decide whether a joint review should be carried out. They discussed doing a broader review to learn more from Adult L's case. It was suggested that using an Appreciative Inquiry approach would help explore Adult L's entire life journey, including childhood trauma and how it affected her later in life. This approach could highlight missed chances for support, gaps in services, ways to work with trauma without causing more harm, and examples of good practice.

An independent author was appointed by the GSAB to undertake the appreciative inquiry with practitioner workshops planned for June 2025 and the draft report due for presentation in October 2025.

Referral 4

This individual was 80 years old at the time of her passing at Queen Elizabeth Hospital in June 2024. She had a diagnosis of mild learning disability and schizophrenia, requiring support with all aspects of personal care. She was able to access respite care when needed.

There were longstanding safeguarding concerns related to her relationship with her husband, with previous discussions held at *Multi Agency Risk Assessment Conference (MARAC). In September 2023, a Community Psychiatric Nurse raised concerns regarding potential neglect by third-party agencies involved in her care. These concerns prompted the submission of incident reports and a review by CNTW's Safeguarding Adults and Public Protection (SAPP) team. Multiple safeguarding referrals were subsequently made to Adult Social Care by CNTW.

Weekly multi-agency meetings commenced in April 2024; however, it is understood that the care provider did not attend these meetings. It remains unclear how concerns were escalated in relation to professional challenge, lack of improvement in care delivery, and the effectiveness of inter-agency communication.

She was admitted to Queen Elizabeth Hospital on 14th June 2024 with suspected urinary tract infection and dehydration. Hospital staff were advised that it was unsafe to discharge her home until a further multidisciplinary team (MDT) meeting could be convened.

Partner agencies are requested to provide any relevant information from September 2023 to June 2024 to support the SARCC group in reviewing the following:

Whether the response to safeguarding referrals was appropriate.

Whether the management of her discharge from acute care was safe and appropriate.

Whether delays in arranging a new care provider contributed to ongoing concerns about her care and safety.

Whether the concerns raised led to improvements in the quality of care, and how repeated concerns were challenged or escalated.

* A meeting where professionals from multiple agencies share information about high-risk domestic abuse cases to develop a coordinated safety plan for the victim and their children.

The SARCC group agreed that the referral did not meet the criteria for a mandatory SAR as there was no evidence upon review that partner agencies had not worked together to safeguard this lady.  However single agency actions were identified for GHFT in relation to discharge protocols in particularly in relation to supply of medication to the patient.  These are being monitored via the QLP group.

Referral 5

The GSAB received a SAR referral in November 2024 from GHFT for a lady who passed away in the QE hospital.  She was admitted to the QE on 7th November after being found on the floor at home by her partner, it isn't clear how long she had laid on the floor but possibly around 4 hours. Upon admission she was lethargic and hypoxic (not known diabetic), with significant bilateral ulceration on both legs. Main diagnosis was sepsis multi organ failure, community acquired pneumonia, PVD (vascular disease), ischaemic leg.  Despite treatment she passed away the same day.

From information contained on Mosaic, Gateshead Council's social care management system she did have identified needs for care and support under the Care Act 2014 following an assessment undertaken in 2015, although she was not receiving any services through the LA. 

Although an inquest was not conducted the coroner commented:

her GP info showed she was actually under GHFT Podiatry and District Nursing wound team having her leg ulcers checked and dressed regularly

She did DNA / cancel a few appointments, but they always re-arranged them for her.

She was last seen a couple of weeks ago and wound was stable and not infected.

Coroner felt not strong enough link to cause of death and is happy with cause of death proposed  by the GHFT Medical Examiner of streptococcus pneumonia, sepsis and multiple organ failure.  The family are in agreement.

There are no concerns around self-neglect as she was actively attending appointments / receiving visits for this wound care. The cause of death is streptococcus pneumonia.

After reviewing the information provided by partners the SARCC group agreed the case did not meet the criteria for a mandatory SAR.

Thematic Review 

The full report, GSAB Chair statement and Executive Summary is available to view on the *GSAB Website.

Following a BBC Panorama programme which aired in December 2023 featuring a care home in Gateshead, the Safeguarding Adults Board commissioned an independent Safeguarding Adult Review.

The focus of the programme was around the employment of overseas workers; however, it also highlighted quality of care issues and safeguarding concerns, relating to former and current residents of the home.

The focus of the review was to consider the robustness of multi-agency enquiries undertaken in relation to the care home, and the purpose was to identify any learning which could improve local multi-agency safeguarding processes.

Following completion of the review in February 2025 the GSAB approved the report recommendations in March 2025 and agreed that a multi-agency panel should be established to lead on the implementation of these recommendations.

This panel is chaired by Nicola Bailey, the GSAB Independent Chair, and includes representatives from:

• Northeast and North Cumbria ICB
• Gateshead Health NHS Foundation Trust
• Cumbria, Northumberland and Tyne & Wear NHS Foundation Trust
• Northumbria Police
• Gateshead Integrated Adults and Social Care (Adult Social Care and Commissioning, Performance   and Quality Assurance)
• Northeast Ambulance Service (NEAS)
• Care Quality Commission (CQC)
• Advocacy Providers (Connected Voice and Your Voice Counts)
• South Tyneside and Sunderland NHS Foundation Trust
• Health Watch

* https://www.gatesheadsafeguarding.org.uk/article/31994/Thematic-Review

Regular progress updates on the work of the panel are provided to both the GSAB and its Executive Group on a quarterly and bi-monthly basis respectively.

The first panel meeting took place in April 2025, where the draft action plan was discussed and updated, with lead professionals identified for each of the recommendations/actions.  The panel also identified practitioners/agencies who would support the completion of these actions, to ensure responsibility and accountability was shared appropriately across multi-agency partners. 

The panel agreed to meet monthly to monitor and track the progress of the recommendations.  Leads will be required to complete and submit a highlight report to the panel meetings to update on progress, key risks, issues and barriers, and any benefits or impact.   Where risks are identified which impact on the GSABs ability to meet its statutory obligations, these will be added to the GSAB Risk Register, as will any recommendations which leads, or the panel view are unachievable.

The Safeguarding Learning and Development Officer is working on a programme of learning events and resources for practitioners to raise awareness of the review, its purpose, the recommendations, and the work of the panel. The events will be hosted both online via Teams and face to face and will take the form of short briefings and workshop events to undertake consultation.  Lead practitioners will also be asked to provide updates on progress at these events.  Resources will be available in a variety of formats including podcasts, videos, briefing documents, and social media posts.