Learning from the ‘Alice and Peter’ Safeguarding Adult Review

The North Yorkshire Safeguarding Adults Board (NYSAB) has published the Alice and Peter Safeguarding Adults Review (SAR) Report and accompanying 7-Minute Learning Brief.

‘Alice & Peter’ were a couple in their seventies, living together in a flat in North Yorkshire. They both sadly died in January 2023, days apart with their cause of death recorded as natural causes. However, Alice & Peter were found to have been living in circumstances of hoarding and self-neglect.

Alice had been well known to numerous agencies within North Yorkshire and although Peter was not well known to professionals, he was identified as needing support after Alice’s death.

As well as identifying good practice around persistent engagement with Alice, the review also highlights important learning for practitioners and organisations working with adults with care and support needs. As a result we encourage colleagues to read the report and learning brief and consider how the findings can support reflective practice and service improvement.

🔗 Access the full report and 7-Minute Learning Brief: Safeguarding Adult Review in respect of Alice and Peter

To support the dissemination of learning, NYSAB has also delivered a Spotlight Session: Learning from the Alice and Peter SAR. The session explores the key findings, themes and practice learning from the review and is available to watch on demand.

🎥 Watch the recorded Spotlight Session: Safeguarding Week Resources

Why does this matter?

The Alice and Peter SAR provides valuable insight into the challenges of working with complex situations involving multiple agencies and managing different professional perspectives around safety planning. The review reinforces the importance of:

• Building and maintaining effective multi-agency communication.
• Understanding the cumulative impact of risks and vulnerabilities.
• Understanding how a person’s past life experiences may inform their current decisions and applying a trauma-informed approach
• Balancing choice, control and autonomy with safeguarding responsibilities.

The learning is relevant across all services and sectors and provides an opportunity to reflect on how we work together to support adults at risk.

What can colleagues do?

After reviewing the report, learning brief or Spotlight Session, colleagues are encouraged to:

• Discuss the learning in team meetings, supervision and reflective practice sessions.
• Consider whether similar themes or challenges may arise in their own area of work.
• Reflect on how effectively information is shared across agencies and services and if any improvements could be made.
• Review how professional curiosity and risk assessment are applied in cases where there is complexity.
• Identify any actions that could strengthen practice, partnership working or service delivery.
• Share the learning with colleagues who may benefit from the findings.

By taking time to reflect on the learning from Alice and Peter, we can continue to strengthen practice and improve outcomes for people who rely on our services and support.