Learning from the ‘Courtney’ Safeguarding Adult Review

The North Yorkshire Safeguarding Adults Board (NYSAB) has published a 7-Minute Learning Brief in relation to the ‘Courtney’ SAR report.

‘Courtney’ is a young woman living in North Yorkshire, with care and support needs and undiagnosed learning disability. A report was commissioned to consider how agencies of the Safeguarding Adults Board worked together to keep her safe in a time period between the loss of her first child at birth, and the birth of her second child.

Due to sensitivities in this case, and in agreement with ‘Courtney’, a decision has been made to publish a 7-minute learning briefing, which can be viewed below.

The review highlights important learning for practitioners and organisations working with adults with care and support needs, particularly around themes of complexity, needs led assessments, mental capacity assessment and risk management. We encourage colleagues to read the learning brief and consider how the findings can support reflective practice and service improvement.

🔗 Access 7-Minute Learning Brief: Safeguarding Adult Review in respect of Courtney

🎥 Upcoming Spotlight Session.

To support the dissemination of learning, NYSAB plan to deliver a Spotlight Session: Learning from the Courtney SAR. The session will explore the key findings, themes and provide advice and signposting for practitioners.

This is planned to take place during National Safeguarding Week commencing 16^th November 2026. Look out for details nearer the time.

Why does this matter?

The Courtney SAR provides valuable insight into the challenges of working with complex situations, particularly when someone is able to mask their needs and understanding. The review reinforces the importance of:

• Relationship building with individuals and their families
• Building and maintaining effective multi-agency communication.
• Identifying and responding to risk.
• Being culturally competent
• Making needs led assessments of eligibility

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 learning brief, 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 to what extent we apply cultural competence in our work with individuals and any barriers to this.
• Review how professional curiosity and risk assessment are applied in cases where there is complexity.
• Consider how we may identify individuals who may be using masking as a coping strategy, or to conceal difficulties, and how we may support them
• 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 Courtney, we can continue to strengthen practice and improve outcomes for people who rely on our services and support.