A presentation of the Herefordshire Safeguarding Adults Board Thematic Review: Premature Deaths.

Ivan Powell (Chair of the Herefordshire Safeguarding Adult Board (SAB)) provided an overview of the premature deaths – thematic review. The review considered the deaths of six individuals in Herefordshire between January 2019 and August 2022, and was jointly commissioned between Herefordshire Safeguarding Adult Board and Herefordshire Council. The principal points included:

1. The review focused on six individuals – five men and one woman – who died between the ages of 24 and 54.
2. In the review, there has been some overlap in which individuals have experienced multiple complex vulnerabilities including:
   1. Criminal justice - six individuals had contact with the criminal justice system, either as perpetrators or victims of crime.
   2. Poor mental health - six individuals had poor mental health.
   3. Substance use – all six individuals used substances
   4. Homelessness – all six individuals had experienced homelessness at some point in their lives, although they were not homeless at the time of their death
3. The over-arching recommendation from the report is clarifying where the overall governance of all the supporting/enabling parts of the system sit between the Health and Wellbeing board and the Safeguarding Adult Board. 

Christine Price asked about recommendation 11.1.3 from the report with regard to the leadership from the different boards involved in the review and enquired about how this is best achieved.

The Chair of the Herefordshire SAB clarified that the Health and Wellbeing board as co-commissioner of the review, in effect, owns the recommendations and action plan resulting in a governance responsibility to make the review land effectively. Additionally, the Safeguarding Adult Board does not have the same level of influence and therefore there is a need to discuss where over-arching governance sits in response to delivering the review.

The Director of Public Health acknowledged the need to discuss governance and how to knit together the work, in dealing with people with more complex needs, between the existing partnerships.

Councillor Diana Toynbee asked who was responsible for investigating non attendance/disengagement at arranged appointments.

The Chair of the Herefordshire SAB noted that the role of the safeguarding board is to seek assurance from the agencies about how they deal with non-attendance.

The Managing Director of Wye Valley NHS Trust recognised the complex area of non-attendance and how this is confronted.

Ewen Archibald (Assistant Director, All Ages Commissioning) noted that on the issue of non-attendance, the thematic review, in addition to Project Brave, emphasises a new, assertive way of approaching the challenge of non-attendance of vulnerable individuals from a range of services and represents a critical risk factor in preventing deaths and its critical in the wider work of supporting people in their journey through homelessness and complex vulnerability.

The Chair of the Herefordshire SAB added that as part of learning from the review, a workshop was held which included managers and practitioners whereby there was frustration in which support was given to an individual through treatment and detoxification and knew that on discharge, there would be a risk they would become homeless. When considering who to put  ...  view the full minutes text for item 73