The North Yorkshire Safeguarding Adults Board (NYSAB) has published a Safeguarding Adult Review (SAR) examining the life and circumstances of ‘Gemma’, a 38‑year‑old woman who sadly died in 2021. The Board will take the recommendations made in the report and sue this learning to strengthen safeguarding practice across North Yorkshire.
The review highlights Gemma’s complex experiences. These included long‑term substance use, mental health challenges, domestic abuse, and the impact of significant childhood trauma. Despite regular contact with multiple agencies, Gemma often found it difficult to engage with support. This highlights the importance of coordinated, persistent and compassionate professional responses.
The Safeguarding Adult Review identifies key themes for improvement, including tackling stigma, improving assessment and screening tools, enhancing multi‑agency working, strengthening assertive outreach, and ensuring effective use of the Care Act and Mental Capacity Act.
Recommendations focus on improving drug and alcohol support pathways, reviewing domestic abuse responses, enhancing suicide risk training, developing clearer multi‑agency frameworks, expanding assertive outreach capacity, and reinforcing the duty to raise safeguarding concerns.
Key Themes from the Safeguarding Adult Review
The SAR identifies nine themes where learning and improvements can be made:
- Supporting people who services find “difficult to engage”
- Addressing stigma and prejudice
- Improving assessment and screening tools
- Strengthening multi‑agency management
- Developing assertive outreach responses
- Equipping practitioners with practical engagement skills
- Using the Care Act and Mental Capacity Act effectively
- Enhancing information governance
- Understanding the impact of Covid‑19 on practice
The review makes a series of recommendations for NYSAB and partner agencies, including which you can read in full here: Safeguarding Adults Review in Respect of ‘Gemma’
Adrian Green, Independent Chair of the North Yorkshire Safeguarding Adults Board, said:
“I want to extend my heartfelt condolences to the family and friends of ‘Gemma’ following her tragic death.
“The North Yorkshire Safeguarding Adults Board (NYSAB) is committed to ensuring that all agencies involved in the Safeguarding Adults Review (SAR) act on the recommendations contained in the review and learn from it.
“’Gemma’ was known to several services for many years, and her complex needs presented significant challenges for those trying to support her.
“However, there were clear shortcomings in her care, and it is vital that these are addressed to prevent similar outcomes 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.
NYSAB extends sincere condolences to Gemma’s family and friends and is committed to ensuring that the learning from this review leads to meaningful improvements in practice and outcomes for adults with complex needs.
Read the full review here: Safeguarding Adults Review in Respect of ‘Gemma’
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