Agenda item

Thematic Review: Premature Deaths

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 the individual in contact with, after discharge, there was no support available to them and quickly returned to alcohol use, undoing the good work from before.


Councillor David Hitchiner asked if there was a record of how many other deaths had occurred.


The Chair of the Herefordshire SAB noted that the SAB were continuing to talk to the coroner about their view on some of these cases. If any of the cases met the criteria for a further safeguarding adult review, then they would come to the SAB. There have been five further referrals for a safeguarding adult review where people had died, however, they did not meet the criteria for a review because the individuals did not have care and support needs. Nevertheless, the SAB have learnt from the world of children and undertakes an adult’s rapid review which identifies some learning from these cases despite not going to formal review.


Ewen Archibald pointed out that the cut-off date for cases to be included in the review was August 2020. Since then there continued to be a significant number of deaths, particularly in the latter part of 2020 and much of 2021. Some of the deaths which have been recorded and identified for learning would be classed as relating to people with multiple complex vulnerabilities. Some, however, would be identified as drug-related deaths without necessarily complex background involved. It was noted that the methodology, as part of the ICB system, would be looked at for monitoring and responding to drug-related deaths more generally.


The Managing Director of Wye Valley NHS Trust asked about how the right level of accountability across agencies, to follow up non-attendance, for example, is resolved.


The Chair of Herefordshire SAB noted that the SAB has recently had a development session with a view to identifying the strategic priorities 2023-26. This would involve that support would be given for governance to be at the SAB.


In addition to the report recommendation, the board agreed therefore that governance should ultimately sit with the SAB and for the board to explicitly identify the needs in order to facilitate that.


The recommendations were proposed, seconded, and approved unanimously.




a)    That the Board considers and comments on the Thematic Review.

b)    That governance should ultimately sit with the SAB and for the board to explicitly identify the needs in order to facilitate that.


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