Safeguarding Adults Review in Respect of ‘Gemma’

The North Yorkshire Safeguarding Adults Board (NYSAB) has accepted the findings and recommendations of a Safeguarding Adult Review (SAR) that the Board commissioned regarding ‘Gemma’, who died in late 2021.

The purpose of a Safeguarding Adult Review is to look at how multiple agencies can best work together to protect people and provide recommendations on how lessons can be learned from their experiences to improve practice and services.

‘Gemma’ was a 38-year-old woman who had contact with a range of agencies in North Yorkshire. The report focusses on understanding issues that informed agency / professionals’ actions and what, if anything, prevented them from being able to properly help and protect ‘Gemma’ from harm.

The report makes a number of recommendations to the individual agencies involved and the North Yorkshire Safeguarding Adults Board as a whole, all of which have been accepted in full. It also highlights several areas of good practice from staff who worked with ‘Gemma’.

North Yorkshire Safeguarding Adults Board offer their sincere condolences to ‘‘Gemma’s’ family and friends.

‘Gemma’ SAR – Summary

‘Gemma’ was a 38-year-old white British woman who lived alone in a housing association flat. She died in late July 2021 as a result of a drug overdose.

‘Gemma’ had a long-standing history of substance use and had been a victim of domestic abuse by a long-term partner. She also experienced mental health challenges, suicidal ideation, and had significant difficulty engaging with professionals and support services.

‘Gemma’s’ life was shaped by numerous adverse childhood experiences, including early exposure to trauma, educational exclusion, and bullying. Records indicate that she developed a substance dependence from the age of 16, which led to a referral to Child and Adolescent Mental Health Services (CAMHS).

In adulthood ‘Gemma’ had an extensive criminal justice history and was frequently involved with health services, reflecting the complexity of her needs and the challenges faced by agencies in providing coordinated support.

The central theme of this SAR is the need for a concerted and assertive response to a woman whose needs were very clear and had been clear for many years. It focuses on improving the response to vulnerable individuals like ‘Gemma’.

The SAR identifies nine key themes:

1. People that services find “difficult to engage”
2. Tackling stigma and prejudice
3. An assessment and screening tool
4. Multi-agency management
5. Assertive outreach
6. Practical interventions with individuals that services find difficult to engage.
7.  The use of the Care Act and the Mental Capacity Act
8. Information governance
9. The impact of Covid 19.

The full report can be viewed below.

SAR Gemma

7 Minute Briefing