104 Death of the Adult at Risk If a concern or complaint is received after an adult at risk has died The concern or complaint could contain an allegation or suspicion that harm or neglect was contributory factor in the adult’s death. The allegation may be made by a family member, partner or friend, a concerned member of employees who is ‘whistle blowing’, or because of a report from the coroner. Such a concern will give rise to action under the Safeguarding Adults Procedures. It will be necessary to try and ensure no further adults are at risk from the same source and, if they are, to take steps to ensure their safety. Decisions may also be taken about whether a serious case review will be undertaken. If the adult at risk dies during the Safeguarding Adults process The Safeguarding Adults process will continue, and an immediate review must take place to decide whether the death was because of the inadequacy of the safeguarding plan or whether poor inter-agency working was a contributory factor. In either of these situations the Police may be involved where there is evidence or suspicion: That the actions leading to harm were intended That adverse consequences were intended Of gross negligence and/or recklessness The coroner will be informed by the police of the death as soon as possible (and before burial or cremation) if harm or neglect is suspected to be a contributory factor. If the incident occurred in a health or social care setting and involved unsafe equipment or systems of work a referral may be made to the Health and Safety Executive (HSE). The HSE will decide whether to investigate. An Enquiry Planning Meeting of the relevant organisations should be convened to review the allegation or complaint and to agree a co-ordinated enquiry/investigation. If there is to be a police investigation, that investigation will take primacy. All organisations will be expected to cooperate in the agreed process. Consideration should be given to whether there should be an independent manager’s review or a request to undertake a SAR to examine the circumstances involved. Please contact the BCP SAB Business Manager or the Dorset SAB Business Manager for the SAR Protocol. Or refer to the SAR Quality Markers. If the adult at risk was a victim of domestic violence and was murdered, a statutory duty to undertake a Domestic Homicide Review (DHR) exists. This is likely to be combined with an SAR. The Home Office must be informed of any learning outcomes from the review through the Chair of the relevant Community Safety Partnership (CSP). Statutory guidance for the conduct of domestic homicide reviews - GOV.UK (www.gov.uk) Appendix 13 – Death of Adult
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