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We need to talk about… Safeguarding Adult Reviews

February 5, 2019

If you were found dead in the street you might expect that there would be a full investigation. I imagine that most of us would want to know that lessons were learned so that our death, however tragic, was not in vain. Perhaps you imagine teams of concerned social workers and police officers trawling through the circumstances that you led you there and doing everything they could to get to the truth. If so, it appears that you are sadly mistaken.

You will have seen recently that a homeless man died in an underpass opposite the Houses of Parliament. Shortly after this another homeless man, Kane Walker, was found dead here in Birmingham city centre. Both had been sleeping rough.

The police have said in both cases that there are “no suspicious circumstances”. This is police code for “we won’t be investigating this any further. It will just be passed on to the coroner.” There will, of course, be a post-mortem to establish the direct cause of death (perhaps the cold, perhaps substance misuse), but as long as there’s no evidence of a crime then there’s nothing further for the police to do.

You might have thought that the local services department would have some responsibility to investigate to understand the wider context that led to these people’s deaths; after all, don’t they have a duty of care to the vulnerable? But social services only have a duty of care if someone has been identified as requiring their support. Yet rough sleepers, by their very nature, have usually slipped through every available gap in the safety net that is supposed to protect them – and, indeed, all of us. The whole reason why people end up sleeping rough is generally because they have either been refused, or have declined, any help. Whilst the two individuals in these cases will each have their own unique story, I’d be prepared to wager a good deal of money that neither were on social services’ radar as being at risk. They had been left to their own devices to live in the nightmarish parallel society of rough sleepers. Now that they are dead there is no ‘context’ to investigate because there were no statutory agencies involved.

If you are an elderly person living in a care home, or a learning disabled adult receiving care and support from the local authority, even if you were accessing local healthcare services, then you come under the protection of the local Safeguarding Adults Board. According to the Social Care Institute of Excellence, the SAB leads “adult safeguarding arrangements across its locality and oversee[s] and coordinate[s] the effectiveness of the safeguarding work of its member and partner agencies… It should concern itself with a range of issues which can contribute to the wellbeing of its community and the prevention of abuse and neglect, such as:

  • the safety of people who use services in local health settings, including mental health
  • the safety of adults with care and support needs living in social housing
  • effective interventions with adults who self-neglect, for whatever reason
  • the quality of local care and support services
  • the effectiveness of prisons in safeguarding offenders
  • making connections between adult safeguarding and domestic abuse.

And that’s the rub: by their very nature, rough sleepers usually have fallen out of any contact at all with statutory agencies and so they do not automatically investigate when a rough sleeper – or, indeed, anyone who is homeless, but living in temporary accommodation – is found dead. So, in the case of Kane Walker, the chair of Birmingham’s Safeguarding Adult Board has suggested to local media that, whilst she’s sympathetic to calls for a safeguarding adult review (SAR – formerly known as a serious case review ), the 2014 Care Act does not give her the power to initiate one automatically. This seems to be the case in rather a lot of cases, as, according to the Birmingham SAB’s website, they have not published any SARs which were initiated since the new Care Act came in. (There were eight requests made for an SAR in Birmingham in 2017-18 and all were declined.)

Yet, even their own annual report says, “The law says Birmingham Safeguarding Adults Board must arrange a SAR when: There is reasonable cause for concern about how BSAB, its partners or others worked together to safeguard the adult, AND the adult died and the SAB suspects the death resulted from abuse or neglect.

Rough sleepers therefore should be a textbook case for SARs. Not only can we say with a fair degree of confidence that, at the very least, self-neglect played a part, but we can say with absolute certainty that there “reasonable cause for concern about how BSAB, its partners or others worked together to safeguard the adult”. All of our major towns and cities have a range of agencies and processes in place to ensure that people don’t have to sleep rough and are kept as safe as possible if they do so – if someone dies in an underpass then surely it is obvious that somewhere those protections have not worked?

The secretary of state for communities and local government, James Brokenshire, has said that he will be writing to the chair of Westminster’s SAB asking for an SAR to be conducted in the Westminster case. One imagines that the chair will be considering that request very carefully. Sadly, Kane Walker did not die on James Brokenshire’s route to work so will have to rely on a request for an SAR from me.

But this should not be a postcode lottery. The deaths of all rough sleepers, and those living in temporary accommodation, should be properly and fully investigated as a matter of course. People who were forgotten about by society should not be forgotten about in death. We need to learn the lessons of these tragedies if we are to make sure they don’t happen again.