Gateshead Safeguarding Adult Review Reports

Roy Safeguarding Adult Review

Gateshead Safeguarding Adults Board commissioned a safeguarding adult review in 2025 into the serious neglect of a gentleman who resided in a care home in Gateshead.

This report examines the effectiveness and reliability of the multi agency safeguarding system through the lived experiences of Roy and his family between October 2023 and July 2024, at the point the original SAR report was finalised Roy was residing in another care home in Gateshead, however sadly Roy passed away prior to final publication of the report.

Roy, aged 77, has faced complex mental health challenges for over five years, alongside serious and enduring physical health conditions. These needs have made it increasingly difficult for him to remain safely at home.

The review focuses on the critical period following Roy's discharge from a mental health hospital, his placement in a Care Home located in a neighbouring local authority, and his subsequent transfer to a local NHS Trust for both mental and physical healthcare—including the amputation of two toes due to deteriorating health.

Key themes explored include:

• Cross-boundary placement challenges
• Discharge planning and Section 117 aftercare
• Diagnostic overshadowing
• Family voice and trauma
• Care home suitability and commissioning

This case highlights the complexities and pressures within safeguarding systems and aims to inform improvements in multi agency collaboration and service provision.

Following a stay in a Gateshead acute hospital a discharge planning meeting was held before Roy's family began searching for a suitable care home. However, the family did not feel supported during this process and felt pressured to find a placement quickly. Multiple care homes assessed Roy but declined to accept him. When one care home did agree, the family had serious concerns about its ability to meet Roy's needs.

Despite these concerns, Roy was discharged within two days of the care home's acceptance. Crucially, no meeting was held between the care home, nursing staff, and social worker to ensure equipment was in place and care information was properly shared. The care home proved unsuitable, and Roy's condition deteriorated both mentally and physically, resulting in frequent hospital admissions due to infections. Throughout the review period, diabetes care was not prioritised in his care plans.

The family continued to feel that they were perceived as too challenging, which added to their distress and frustration.

This update is included prior to the recommendations as a timely reminder of the urgency for action and improvement. It underscores the need for better coordination, communication, and support across agencies—especially during transitions of care.

You can access the full report below.

Gateshead Safeguarding Adults Board Roy SAR (PDF, 12 MB)

Thomas Safeguarding Adult Review

Gateshead Safeguarding Adults Board commissioned a safeguarding adult review in 2023 into the death of Thomas, a 41 year old gateshead resident who was found dead in his home.

Thomas's case highlights critical issues in safeguarding and support for individuals with complex needs transitioning through the criminal justice system.

After serving a 10-year prison sentence, Thomas was released in January 2020, but returned to prison on remand in December 2020. He was released again in February 2021, and tragically died just six days later.

Thomas had a long-standing history of involvement with the criminal justice system and was identified as a source of risk in domestic abuse incidents. In the final months of his life, professionals raised concerns about his deteriorating mental health, substance use, poor self-care, and the unsuitable condition of his living environment.

This case review explores the multi agency response to Thomas's needs and the safeguarding challenges that emerged. It aims to inform future practice and improve outcomes for individuals in similar circumstances.

You can access the full report and a PowerPoint summary of key learning points below.

Gateshead SAB - Thomas Safeguarding Adult Review Report 2024 (PDF, 549 KB)(opens new window)
Gateshead SAB Thomas Safeguarding Adult Review Powerpoint (PDF, 826 KB)(opens new window)
Thomas (Adult C) 7 Minute Guide (PDF, 142 KB)(opens new window)

Adult B

Adult B was 89 years old at the time of her passing. She lived with her son, who was also her primary carer, and had a diagnosis of dementia.

In the period leading up to her death, serious concerns were raised regarding potential neglect, prompting a multi agency review to better understand the circumstances and identify opportunities for learning and improvement.

This case highlights the importance of recognising and responding to safeguarding risks in the context of older adults with complex care needs, particularly where family members are acting as carers.

Read the Adult B Executive Summary (PDF, 159 KB)(opens new window)