Worried about an
adult at risk?

Report a Concern

Lessons Learned Reviews of ‘Mrs S’

Two independent Reviews were commissioned by the North Yorkshire Safeguarding Adults Board regarding ‘Mrs S’. The first of these, an independent Lessons Learned Review was following a number of safeguarding alerts and complaints raised by one of Mrs S’ daughters between 2013-2017 regarding her mother’s care in a nursing home.

In the time since this review was commissioned Mrs S has sadly passed away. To assure the Safeguarding Adults Board that Mrs S received quality care and treatment, and that any multi-agency lessons are identified and acted upon, a second independent case review which evaluated the care and treatment of Mrs S in the final weeks of her life has also been completed.

Both reports can be viewed below, together with a response to the reports from one of Mrs S’ daughters.

Lessons Learned Review ‘Mrs S’

Independent Health Review ‘Mrs S’

Addendum ‘Mrs S’ Review

Family Comments

‘Mrs S’ Delivery Report

Access training

Mo

Our latest news

Three women behind a table which is covered with safeguarding leaflets.
21 Nov 2025

Every Week is Safeguarding Week

As Safeguarding week comes to a close, we are reflecting on what has been an incredible opportunity to share knowledge,...

Read More
A hand holding a pen and writing on a book
20 Nov 2025

Learn, Reflect, Prevent.

Learn, Reflect, Prevent

Read More
MoreView all our news