Wolverhampton Safeguarding Adults Board has today (Thursday 6 October) published the findings of a Safeguarding Adult Review into the death of a 50-year-old woman.

It centres on the events in the month before the woman, referred to as Alison in the review, passed away in February 2015.

It was commissioned by Wolverhampton Safeguarding Adults Board last year to ascertain the involvement of agencies and determine what could be learned from the case. The report was prepared by independent author Robert Lake, and highlights a total of 29 actions identified by the agencies involved and subsequently agreed by the Safeguarding Adult Review panel. The actions have either already been implemented or are in the process of being completed.

Alan Coe, Chair of Wolverhampton Safeguarding Adults Board, said: “This is a very sad case and on behalf of Wolverhampton Safeguarding Adults Board and the agencies who were involved with Alison I would like to express our condolences to her family and friends. “As the report author says, she was a remarkable woman who didn't let disability prevent her from living life to the full.

“We commissioned this Safeguarding Adult Review to determine whether there was anything that the agencies or individuals working with Alison in the last weeks of her life might have done differently.

“We hope that the issues it has raised, and the action plans which have been developed by the agencies concerned, will ensure that lessons are learned and, as far as possible, professionals are able to prevent similar harm from occurring again.

“The report highlights a number of areas of best practice and recognises that on the whole Alison and her family were happy with the care that she had received over a number of years. The report also identifies some key areas where this was not the case.

“The report was undertaken with the direct engagement of Alison’s family who are in full support of the findings and recommendations and I would like to take this opportunity to thank them for their involvement in the review.”

The recommendations include reviewing the way people with communication or learning difficulties are supported, including through the use of advocates, and improving record keeping and the escalation process. The agencies involved in the review included Wolverhampton Safeguarding Adults Board, the City of Wolverhampton Council, Royal Wolverhampton NHS Trust, West Midlands Ambulance Service, the Care Quality Commission, a housing association and a recruitment agency.

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