Learning from ‘Marie’: Safeguarding Adults Review – Turning Lessons into Action.

The North Yorkshire Safeguarding Adults Board (NYSAB) has recently published a Safeguarding Adults Review (SAR) following the tragic death of ‘Marie’, a 30-year-old woman who sadly took her own life in March 2023 after being in contact with several agencies across North Yorkshire.

This review is a vital opportunity for reflection and change. It asks difficult questions:

What stopped agencies from being able to protect Marie?
What do we need to do differently to prevent this happening again?

Why This Matters

Safeguarding Adults Reviews are about learning, not blame. They shine a light on gaps in systems and practice, helping us build stronger, safer systems for individuals with care and support needs. Marie’s story reminds us that safeguarding is everyone’s responsibility, and that collaboration, compassion, and consistency can save lives.

What We Learned

The SAR identified 10 key recommendations for improvement which can be reviewed in more detail in the Marie SAR. Here are some of the most important themes:

1. Cultural Competence: Staff need the tools and training to work effectively with Gypsy, Roma, and Traveller communities.
2. Trauma-Informed Practice: Every agency must embed approaches that understand and respond to trauma.
3. Mental Capacity Act Guidance: Clear, consistent use of the MCA is essential, especially when mental health fluctuates.
4. Assertive Outreach: Services like Drug and Alcohol teams and Mental Health teams must actively reach out to those at risk.
5. Joined-Up Working: Multi-agency case conferences should be routine for adults with complex needs.
6. Timely Follow-Up: Emergency Departments must ensure follow-up within 40–72 hours after self-harm or mental health crises.
7. Better Coordination: Agencies need robust systems to oversee care for people receiving support from multiple services.

A Message from Our Independent Chair

Adrian Green, Independent Chair of the North Yorkshire Safeguarding Adults Board, said:

“On behalf of the board, I would like to offer my sincere condolences to the family and friends of ‘Marie’.

This was a complex case, and while it is encouraging that the Safeguarding Adults Review recognised strong practice across agencies, it also identified a number of areas where lessons can be learned to prevent similar incidents in the future. The review highlights the importance of culturally competent, trauma-informed and evidence-based practice across all agencies, supported by clear frameworks, robust protocols and consistent multi-agency collaboration. Embedding this will to help ensure adults with complex needs receive coordinated, responsive care that reduces risk and improves outcomes

The North Yorkshire Safeguarding Adults Board (NYSAB) is committed to ensuring that all agencies involved act on the recommendations contained in the Safeguarding Adults Review (SAR) and learn from it.

As the Independent Chair I will ensure that the NYSAB will action the recommendations from the report and deliver the tangible improvements in practice and procedures to help prevent similar harm to vulnerable people in the future.”

What Happens Next?

The Board will now work with all partner agencies to develop an action plan, aligning with our 2025-2028 Strategic Priorities, for instance Priority 3: Confident Practice, which focuses on trauma-informed approaches and the Mental Capacity Act.

Marie’s story is a powerful reminder: safeguarding is not optional, it’s essential. Together, we can make North Yorkshire a safer place for everyone.

You can read the full review here: Marie SAR.