Annual Report 2022/23

Each year the Leeds Safeguarding Adults Board publishes an Annual Report setting out its work and achievements over the last 12 months.  This report summaries the work of the Board during 2022/23. It is available as a video summary on Youtube:

Leeds Safeguarding Adults Board Annual Report Summary 2022 - 2023 - YouTube  

Alternatively the full report can be read below:


i. Foreword

1.   Leeds Safeguarding Adults Board

1.1        What is Safeguarding Adults?

1.2        What are Safeguarding Adult Boards?

1.3        Which organisations are on the Board?

1.4        Board governance arrangements

2.  Ambition One: Developing citizen-led approaches

3.  Ambition Two: Improving awareness

4.  Ambition Three: Citywide approaches

4.1  Our Citizen-led multi-agency safeguarding policy and procedures

4.2  Self-neglect

4.3  Multi-agency working

4.4  Exceptional Risk Forum

5.  Ambition Four: Learning from experience

5.1 Learning from good practice

5.2  Safeguarding Adults Reviews

5.2.1  Our Completed Reviews during 2022/23

5.2.2  Our Published Reviews during 2022/23

5.2.3  Our Ongoing Safeguarding Adults Reviews

5.2.4  Our decisions to not progress reviews

5.2.5  Our new SAR Sub-group

5.3  Learning through Quality Assurance and Performance

5.4 Learning and Development

6.  Going Forward 

6.1  Our Ambitions for 2023 to 2024



As the Independent Chair of the Board, one of the most rewarding aspects of the role is to be part of a Board that is so committed to listening to citizens, co-production and working with and alongside communities. Being Citizen-led is one of our four key ambitions.

We know there is lots more to learn and do in this respect but an important lesson has been not just to hear people's voices but to embrace them as our own.

Terms like Making Safeguarding Personal – the government led-policy are absent from our Board meetings; we have instead adopted the language of Talk to me, hear my voice - the Citizen-led philosophy given to us by citizen groups in Leeds. This is the way we need to work, allowing citizen and community groups to reclaim the language of being safe, and to seek their help in defining what good support looks like and feels like.

As we embark on a new project to support people within ethnically diverse communities to access safeguarding services, we need to work in this same way, to learn from and co-produce ideas and initiatives with communities.

We have made some good progress towards being citizen-led in recent years, we have virtual networks, regular consultations, an exciting new Citizen Reference Group and a wonderful Friends of the Board Network of committed partners that advise us and help us to promote safeguarding awareness.

This year we produced our new animated film. Aimed at members of the public this short film explains what abuse is, what neglect is and how people can get help for themselves or someone they know. The narrator is based on the image of one of our Safeguarding Ambassadors, a group of people with learning disabilities who champion the Talk to me, Hear my voice message in Leeds. There is simply no one better, as it is the voices of citizens and communities within Leeds that need to be at the heart of all our work.

We are still learning and still taking new steps, but I hope the Annual Report gives you a flavour of these citizen-led ambitions which we plan to build upon during the year ahead.


Richard Jones CBE,  

Leeds Safeguarding Adults Board, Independent Chair


1. Leeds Safeguarding Adults Board 2022/23

1.1  What is Safeguarding Adults?

The aim of safeguarding adults is to:

  • prevent harm and reduce the risk of abuse or neglect to adults with care and support needs
  • stop abuse or neglect wherever possible
  • safeguard adults in a way that supports them in making choices and having control about how they want to live
  • promote an approach that concentrates on improving life for the adults concerned
  • raise public awareness so that communities as a whole, alongside professionals, play their part in preventing, identifying and responding to abuse and neglect
  • provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult
  • address what has caused the abuse or neglect[1]

1.2 What are Safeguarding Adults Boards?

Safeguarding Adults Boards are established under the Care Act 2014. Their objective is to safeguard adults who cannot protect themselves from abuse, neglect and self-neglect, because of their care and support needs.

The Board is a strategic body. It does not deliver any frontline safeguarding services. Instead it works strategically to coordinate the work of its members and other agencies and ensures the effectiveness of what each of its members does[2].

Safeguarding Adults Boards have specific duties as set out in Schedule 2 of the Act[3]. These relate to producing Annual Reports, Strategic Plans and the undertaking of Safeguarding Adults Reviews.

1.3 Which organisations are on the Board?

A wide range of organisations are represented on the Safeguarding Adults Board in Leeds. This includes senior representatives from:

  • Leeds City Council: Adults & Health,
  • West Yorkshire Police
  • West Yorkshire Integrated Care Board
  • Leeds and York Partnership NHS Trust
  • Leeds Teaching Hospital NHS Trust
  • Leeds Community Healthcare NHS Trust
  • HMPPS: Probation Service
  • West Yorkshire Fire and Rescue Service
  • Leeds City Council: Housing
  • Advonet, representing the third sector.
1.4     Board governance arrangements

Independent Chair

 The Board appointed Richard Jones CBE to be its Independent Chair, whose role involves providing leadership, challenge and support to the Board in achieving its ambitions.


The Board has generally adopted the agile working practice of Task & Delivery Groups, with Board Members acting as workstream Leads. Each project is commissioned by the Board and with Task & Finish Group reporting directly back to it.

The Board however retains two standing sub-groups:

  • The Quality Assurance and Performance Sub-group which oversees Board assurance processes and the development of multi-agency guidance and procedures.
  • The Safeguarding Adults Review Sub-group which oversees the management of Safeguarding Adults Reviews and advises the Board on required actions.

Board Strategy Unit

The Board employs a small team to act as a dedicated resource to support its workstreams and assist the Board in achieving its strategic ambitions.

Key strategic partnerships

The Board has close working relationships with a range of organisations and networks that enable the Board to work in partnership towards making Leeds a Safe Place for Everyone.

This includes:

  • Mental Capacity Act Local Implementation Network
  • Leeds Safeguarding Children Partnership
  • Leeds Safer Stronger Communities

The Chairs from the Safeguarding Adults Board, Safeguarding Children Partnership and Safer Stronger Communities meet regularly to share information and identify common priorities and opportunities for collaborative working.

Funding arrangements

The Board is funded by the West Yorkshire Integrated Care Board, Leeds City Council: Adults & Health, and West Yorkshire Police. This enables the Board to fund specific workstreams, commission an Independent Chair and a Strategy Unit to support its work.

LSAB Ambitions

The Board Strategic plan is based around four ambitions. The following pages explain these alongside an outline of our progress.

2.  Ambition One

Develop citizen-led approaches to safeguarding

What we want to achieve for citizens in Leeds:

'I am able to influence how people are safeguarded in Leeds'

We said we would work with citizens and communities to develop our approach to safeguarding in Leeds.  Our achievements include:

  • A Citizen Reference Group: Our exciting new reference group provides advice, support and challenge around Board workstreams. During 2022/23 they have advised on the Leeds Self-neglect Strategy, Safeguarding Referrals, Board priorities and the use of Advocacy in Safeguarding.  This citizen perspective helps to shape and direct our work.
  • A Friends of the Board Network:  We have established a hugely supportive and helpful Friends of the Board Network that helps us promote safeguarding awareness, supports our key projects, and provides feedback on their experiences. There are currently twenty-six network members primarily from community and third sector organisations. During 2022/23 they have taken part in listening events around referral processes and met with the independent chair to provide feedback on their experiences of safeguarding adults in Leeds.
  • A new consultation process: This year we have established a new online consultation process. It enables anyone to provide us with feedback on our priorities or our resources at any point during the year. We collate all the feedback for the Board to hear directly what people are telling us.
  • Annual consultation on the Board's strategic plan: This consultation led to the inclusion of new actions on our plan, such as training and review of referral processes.  We highlight these actions that arose from our consultation throughout this Annual Report in the relevant section.
  • Leeds Self-neglect Strategy:  We were able to consult with 20 people with lived experience of self-neglect and services. Their views are included within the Strategy and have directly shaped the actions within the plan.

  • Annual listening event: This year this involved members of community organisations talking to us about the safeguarding needs of ethnically diverse communities in Leeds. We can tell you more about this in our next section about promoting awareness of safeguarding adults.

  • Virtual Network. Over 240 people are signed up to our Virtual Network that enables them to take part in consultations on our work and priorities. The network includes both members of the public and practitioners.

We said we would keep finding ways for citizen voices to directly influence safeguarding practice. This has involved:     

  • The Talk to me, hear my safeguarding story project sought citizen feedback of their experiences of safeguarding adults. This project concluded in 2021/22 and we have collated the learning this year into a practitioner briefing of key five citizen messages, to let practitioners know what citizens are telling us positive experiences of support. 
    • Talk to me, hear my voice:  Good communication can make all the difference to someone's support and their experience of safeguarding.
    • The importance of advocacy:  The role of an advocate is to provide a person with support to be involved in decisions. A key message from people with lived experience is that when needed, it is important that independent advocates are sought as early as possible.
    • Help me to know what to expect:  People welcomed knowing about the safeguarding process, what was happening next, and how they would be involved.
    • Outcome meetings can provide closure:  A key message from people with lived experience, is that sometimes an outcome meeting with the practitioners involved can help to bring closure to a traumatic experience.
    • Recognise the impact you can have:   In difficult and sometimes traumatic circumstances, everyone needs to appreciate the valuable roles they have and the positive impact they can have on someone's life. One person said: "Social services and my advocate were literally life savers… my experience was fantastic'.

We will need to do some more work next year, to find the best ways of hearing these views in the future.     

  • Advocacy within Safeguarding: One of the key messages from the Talk to me, hear my safeguarding story project above, was the importance of advocacy to help facilitate people's involvement in safeguarding decisions. As a result, Advonet and Leeds City Council: Adults & Health have led a project to better understand how people are supported and represented within safeguarding. This has involved a national survey of practice, new Leeds training, and the inclusion of advocacy representation within the Adults & Health quality assurance frameworks and processes.
  • Advonet have also worked with Leeds City Council's Children and Families Service and Strengthening Families Protecting Children project to develop a Peer Advocacy model for parents who are working with Social Workers.  The peer advocates are trained to help parents where their children are assessed as being at risk and subject to a statutory process, to think through their needs and to feel more empowered within a challenging family situation.  The advocacy support is provided by people with Lived Experience and independent from the process so that parents can feel someone is there to support them through the process and ensure they have a voice.
  • LSAB Citizen Ambassadors: We are very proud of our LSAB Citizen Ambassadors programme. Having helped us to develop our Citizen-Led Safeguarding Adults Policy and Procedures in 2019, Leep1 a learning disability self-advocacy organisation have continued to present their Talk to me, hear my voice film and provide talks to practitioner groups in Leeds. You can see the Citizen Ambassador short films on our YouTube channel.
  • Adult Social Care Ambassadors: Adults & Health has also been developing its approach this year with its citizen ambassadors, who can talk to communities about a range of care and support issues, including safeguarding adults.

We also said that we have wanted to capture this citizen-led approach within our governance documents

  • Whilst we have embedded the citizen-led approach into our philosophy, we have more work to capture this formally within a new Board Governance document.  We want these governance arrangements to be co-produced with the inclusion of citizen values and in a way that is meaningful to communities.
  • We have heard that that our logo isn't meaningful to members of the public, it doesn't say what safeguarding is, and so are we are currently holding a LSAB logo competition and consultation on what our new design should be. We will adopt the new logo as part of our new governance arrangements.

 3.  Ambition Two:

Improve awareness of safeguarding across all communities and partner organisations

What we want for Citizens in Leeds:

'I receive clear and simple information about what abuse is, and how I can get help'

'I am confident that services that I go to know how best to support me'

 We know that not everyone knows and understand what safeguarding is, and so we are committed to promoting awareness and understanding each year.

We said we wanted everyone to know how to seek help and to be confident to do so. Our work has included the following:

  • Everyone's responsibility: All Board member agencies promote safeguarding awareness within their organisations and networks, according to the types of service they are.
  • Safeguarding Awareness sessions: The Board employs an Engagement Officer who continues to offer awareness sessions for community and citizen groups across Leeds.
  • Safeguarding within ethnically diverse communities: The Board decided to invest in understanding how well safeguarding adults was understood and accessed by ethnically diverse communities within Leeds. The Board partnered with Voluntary Action Leeds who were well placed to work with community workers and community groups to understand any barriers to accessing safeguarding services. Members of various community groups who took part also attended the Board Listening Event to speak directly to the Board about their views and experiences.  This approach has highlighted an opportunity to coproduce a new approach of supporting community organisations to support their communities. The Board plans to take this forward next year.
  • A new public information film: "Supporting people to be safe from abuse and neglect in Leeds". In a simple and straightforward way, it explains what abuse, neglect and self-neglect are and how to get help for yourself or someone you know. It is available in BSL and 5 other language translations.  All of these can be viewed on our Youtube channel, alongside the "Tricky Friends" short film that we published last year.
  • Safeguarding Resources: We continue to provide leaflets and posters that were developed through citizen focus groups and consultations. These are based upon citizen-led messages about how safeguarding can change and improve people's lives. They remain available to download from the Board website.
  • Social Media: Leeds Safeguarding Adults Board has increased its presence on social media with 1718 Twitter Followers at present. This has proved a helpful way to promote safeguarding adults news and information. You can follow us on:



We said we wanted to support organisations to know and understand their safeguarding responsibilities. Several actions here came directly from our Strategic Plan consultation:

  • Links with Universities and Further Education Colleges: One action we took from our Strategic Plan consultation was to make closer connections with safeguarding lead officers at universities and further education colleges in Leeds. Our Independent Chair met with lead officers June to hear their views and to establish closer working connections.
  • Safeguarding referral processes: A second action we took from Strategic Plan consultation was to establish a listening event in relation to safeguarding referral processes. This included several senior managers from Adults & Health and a range of people from our Friends of the Board Network or other wider partners who had expressed an interest in attending. This was a hugely helpful event in understanding and exploring how safeguarding works in practice for all agencies involved. The plans to develop local closer links to local community social work teams was particularly welcomed by those who attended. Many felt that access to such advice would sometimes remove the need for a formal safeguarding referral to be made.

  • Safeguarding Training: A third action that we took from our Strategic Plan consultation was in relation to the provision of safeguarding training. In response, Adults & Health undertook a consultation with internal staff teams and external adult social care organisations in Leeds asking about their Safeguarding training needs and the current training offer. With the learning from the consultation a Safeguarding Adults resource library is being developed with wider subject areas, as well as with what resources are already available in the city. Further workshops, further training and masterclasses are being commissioned in the areas requested to support the needs of the workforce. An example of this is training for volunteers, which is providing an opportunity to link in with, and gain the views of the Friends of the Board Network.This review is ongoing and the training needs analysis will lead to a new Safeguarding Training Strategy for Adults & Health.
  • Multi-agency training: There is also an active task and finish group of the Board exploring how multi-agency safeguarding training can be provided. Such an approach could enable practitioners from different organisations who work together to also train together. This may also help to share training resources across the partnership. The Board is currently exploring ideas and options and plans to take this forward next year.
  • Safeguarding Week 2022: In June 2022 we held Safeguarding week in partnership with Children Safeguarding Partnership and Safer Stronger Communities.  We hosted online sessions about Self-neglect that were facilitated by Suzy Braye and Michael Preston-Shoot, both leading national researchers on the subject. We also used this time to promote awareness of our Self-neglect policy, professional curiosity and information sharing guidance.

  • Safeguarding Networks: Housing associations: Housing Leeds have established a safeguarding network with Housing Associations in Leeds. Meeting quarterly this provides for sharing learning, safeguarding developments and feedback from housing associations. This year, these meetings have included sharing information about the Leeds Self-neglect Strategy and learning from Safeguarding Adults Reviews.

  • E-bulletin: We use our e-bulletin to help practitioners, services and organisations keep up to date with local and national safeguarding developments. Regular bulletins are now received by an audience of 830 people/organisations. For more information, or to sign up to receive bulletins, go to LSAB Bulletins.

4. Ambition Three:

Develop citywide approaches to safeguarding practice

What we want for citizens in Leeds:

'I am confident that practitioners will work together and with me to get the best outcomes for me'

We said we wanted there to be effective multi-agency safeguarding practice across the city.

Our key areas of focus this year were:

4.1  Our Citizen-led multi-agency safeguarding policy and procedures

The Board remains committed to its Citizen-led multi-agency safeguarding adults policy and procedures established in 2019 and updated in 2021. The multi-agency policy and procedures provide the framework around how all organisations in Leeds must work together and with the adult at risk, when a person is experiencing or at risk of abuse, neglect or self-neglect.

The Leeds approach to its policy and procedures was unique in its time, as it was co-produced with the input of nine citizen groups, ensuring that Leeds citizen voices were at the centre of our safeguarding procedures. Their message, Talk to me, hear my voice emerged from this work and has become a Leeds practice principle.  

The Leeds Safeguarding Adults Board is regularly asked to talk to other Safeguarding Boards or networks about this approach and how it was developed.

Use of the multi-agency safeguarding procedures during 2022/23

The local authority leads and coordinates the work of the partnership to safeguard adults with care and support needs from abuse, neglect and self-neglect within Board's multi-agency safeguarding adults policy and procedures. This responsibility is given to them under the Care Act 2014. The following information provides a brief overview of this work:

Safeguarding Referrals: There were 13,526 safeguarding referrals made over the last 12 months. This reflects an expected increase of 11% based upon the rate of growth in referrals over the last 5 years.

Safeguarding Enquiries[4]: When a referral is received, Leeds City Council: Adults & Health will need to decide whether to undertake a safeguarding enquiry. This decision will be made based upon the criteria set out within Section 42 of the Care Act 2014. 

In 2022/23, 25% of all safeguarding referrals resulted in a safeguarding enquiry. This is consistent with figures for 2021/22. On occasions when a safeguarding enquiry was not required, other forms of support, advice, information or other services will have often been provided dependent upon the nature of the risks, the specific concerns and the person's particular needs.

The nature of the concerns: During 2022/23 safeguarding enquiries concerned the following types of possible abuse.

  • Neglect and acts of omission: 38%
  • Physical abuse: 23%
  • Financial or material abuse: 12%
  • Psychological abuse: 9%
  • Self-neglect: 6%
  • Domestic abuse: 4%
  • Sexual abuse: 4%
  • Organisational abuse: 2%
  • Discriminatory abuse: <1%
  • Sexual exploitation: <1%
  • Modern slavery: <1%

Please note however, that a person may experience more than one type of abuse at the same time.

The support needs of people at risk:

 Safeguarding works to help adults with care and support needs, who are unable to protect themselves without support. During 2022/23 the safeguarding enquiries undertaken concerned people with the following care and support needs: 

  • Physical Support: 35%
  • Support with Memory & Cognition: 23.2%
  • Learning Disability Support: 18.1%
  • Mental Health Support: 16.4%      
  • Social Support: 3.3%
  • Sensory Support: <1%

    Please note that a person may have more than one form of support need.

    The ethnic diversity of people at risk:

    During 2022/23 the ethnicity of those supported was:
  • White - 82.2%
  • Mixed / Multiple - 0.9%
  • Asian / Asian British - 2.6%
  • Black / African / Caribbean / Black British - 2.6%
  • Other ethnic group - 1.5%
  • Refused - 0.3%
  • Undeclared/unknown - 10.14%

According to census records for 2021, 79% of the Leeds population are White and so may be slightly over-represented within safeguarding enquiries. Conversely some minority ethnic communities under-represented. For these reasons the Board is currently undertaking a project to work with diverse communities to make support more accessible (See Ambition 2).

Outcomes of safeguarding enquiries
Support provided within the multi-agency policy and procedures should always be with recognition of the person's desired outcomes and with the objective of reducing risk to that person's safety and well-being. 

  • Desired outcomes: 

During 2022/23 these desired outcomes were Fully achieved on 69% of occasions and Partially achieved in 25%. It should be noted however, that it is not always possible to achieve someone's desired outcomes, these can sometimes be unachievable, or actions may be required for the safety of others contrary to the person's wishes. Again it is necessary to look at individual cases to understand why a risk may remain.

  • Risk reduced or removed:

During 2022/23 the risk experienced by the person was reduced or removed in 87% of safeguarding enquiries. Sometimes people may choose to live with risk or it may remain with strategies in place, and so it is necessary to look at individual cases to understand why a risk may remain.

4.2  Self-neglect

We said we would develop our approach to self-neglect in Leeds and so in January 2023 we published the Always Care: Leeds Self-neglect Strategy

 ased upon the views of citizens with lived experience, the experiences of frontline practitioners, and our learning from Safeguarding Adults Reviews in Leeds the Leeds Self-neglect Strategy sets out a comprehensive three-year plan to improve outcomes for people who self-neglect.

It is based around 4 core pillars:  

  • People:            Always work with and alongside people who self-neglect
  • Prevention:     Always work to prevent the risk of serious self-neglect
  • Partnership:    Always bring partners together to support those at risk
  • Practice:          Always develop and support best practice in Leeds

 The citywide plan recognises that whilst the Leeds Safeguarding Adults Board has a leading role, that work to support people who self-neglect is also a responsibility for wider strategic bodies and partnerships, and there is a need for a collective approach to achieve the best possible outcomes.

 The Board will be closely monitoring and reviewing its plan over the next year and hopes to hold a partnership event during the latter part of the year to promote the strategy.

4.3  Multi-agency working

We said we would consider how we can best promote effective multi-agency working.  Safeguarding Adults Reviews and our Appreciative Inquiry within Leeds have highlighted the importance of effective multi-agency working practices.

 To help us develop our multi-agency working practices in Leeds, the Board has partnered with the Social Care Institute of Excellence (SCIE) as a leading sector improvement body.  During 2023/24 SCIE will be working with sector leads to explore new approaches that can help strengthen consistent multi-agency working practices across the city.

 Initial meetings have planned the approach and identified key sector leads to steer the project. This work will continue to be taken forward over the next year.

4.4  Exceptional Risk Forum

 We said we would continue to provide an Exceptional Risk Forum. The LSAB Exceptional Risk Forum was established by the Leeds Safeguarding Adults Board in recognition that sometimes, despite the best efforts of agencies to work together to intervene and provide support to someone, an exceptional risk to their safety can remain.

First established in September 2021 the forum has now held over 30 discussions regarding individuals with some of the most complex and challenging circumstances in the city.  The Exceptional Risk Forum offer agencies a fresh perspective and multi-agency advice and recommendations as to how that person's risk could be reduced. The approach and has been positively evaluated by participants.

The Forum is chaired by Leeds City Council: Adults & Health and well represented by all NHS Trusts, Forward Leeds, Housing and the Integrated Care Board.

Forum has also heard of much excellent multi-agency working in Leeds, with practitioners clearly exploring all possible avenues to minimise risk and promote an individual safety and wellbeing.

5. Ambition Four:

Learn from experience to improve how we work

What we want for Citizens in Leeds:

'I am confident that learning from my experience will help others'

Our ambition is to ensure we learn from citizen experiences to improve safeguarding arrangements in the city.

5.1 Learning from good practice

We said we would learn from good practice. Overseen by the Learning & Development workstream, the Board piloted a new approach of holding an Appreciative Inquiry into the circumstances of a man who had been living a street-based life for many years and whose circumstances indicated self-neglect, who had complex and long-standing needs. An Appreciative Inquiry involves identifying the good practice, what went well, why was this, and how can be build upon this going forward.

This involved a two-stage supported conversation, firstly with practitioners who were directly involved in providing care and secondly with managers who supported that practice. The person at the centre of these concerns was also invited to take part. He was pleased for the Appreciative Inquiry to take place but chose not to take part himself.

The Appreciative Inquiry focussed on the strong and effective multi-agency working that enabled him to be supported to move from living on the street to living in his own accommodation. It was widely accepted as a valuable learning experience from all that took part and has inspired the continuation of these approaches by the Board and partners.

These are just a few of the key learning messages identified by the review – collectively these approaches made all the difference.

People: Work with and alongside people who self-neglect

The inquiry identified the importance of:

  • A person-centred approach
  • A strengths-based approach
  • A lead person / lead agency with clear and agreed roles

Practice:  Always develop and support best practice in Leeds

The inquiry identified the importance of:

  • Building the team around the person
  • Good communication
  • Good information sharing
  • Enabling and supportive managers

Partnership: Always bring partners together to support those at risk

The inquiry identified:

  • Working together works – it is often the case that no one person or agency can make the difference on their own.

Prevention:  Always work to prevent the risk of serious self-neglect

 The inquiry identified the importance of:

  • Intervening early to minimise risks

We are taking forward this learning through the Leeds Self-neglect Strategy.

5.2  Safeguarding Adults Reviews

We said we would learn through Safeguarding Reviews (SARs).

 Safeguarding Adults Boards (SAB) have a statutory duty to undertake Safeguarding Adults Reviews when:

'….an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult'.

SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect"[5].

The purpose of the review is to identify learning that can be used to improve outcomes for others, it is not to find fault and apportion blame

5.2.1  Our Completed Review during 2022/23

Ms C was in her fifties when she died in hospital. The cause of death was recorded as decompensated liver, alcoholic liver disease and sepsis secondary to self-neglect and widespread pressure sores.

The Safeguarding Adults Review learning was focused on challenges of engagement, multi-agency working / meetings and supervision / management oversight.

The report will be published during 2023/24 following the completion of an Executive Summary; however the learning has already been integrated into the Leeds Self-neglect Strategy and Leeds Safeguarding Adults Board, Strategic Plan.

This includes the following learning outcomes around the importance of:

  • Good practice around mental capacity assessment.
  • Managing reluctance to engage with services
  • Use of professional curiosity
  • Effective supervision
  • Maintaining a Board focus on Self-neglect.

5.2.2  Our Published Reviews during 2022/23

Our Annual Report last year reported on the learning from two completed Safeguarding Adults Reviews. These are now published.

  • Safeguarding Adults Review: Mike (a pseudonym for the person's real name)
The Board undertook a Safeguarding Adults Review in relation to Mike who died following an attack on him by another resident within the supported accommodation in which he lived. Both men had significant mental health conditions and the relationship had becoming increasingly acrimonious in the year leading up to the attack.

The Board commissioned independent authors to undertake the review, who concluded that "although there were lessons to be learnt in respect of how different organisations can work together to better support adults with care and support needs, the tragic outcome could not have been predicted".

The report and action plan are now published on the Board website.                                                                        
  • Thematic Safeguarding Adults Review: Self-neglect
During 2021, five people were referred to the Board for a Safeguarding Adults Review, involving circumstances of self-neglect. For this reason, the Board concluded that a thematic SAR was the best way to capture the learning. The thematic review report included the following learning themes:
  • Fire safety
  • Alcohol use and its impact on self-neglect
  • Mental capacity (inclusive of executive capacity)
  • Think family approaches
  • Multi-agency working and meetings

The Thematic Review was published on the Board's website during 2023, which also inspired the development of the Leeds Self-neglect strategy that was produced and published as a response to this review and our wider learning.

  • Joint Statutory Review: Jake (a pseudonym for the person's real name)

A Joint Statutory Review is a term we have used to describe a review that was undertaken jointly by Safer Leeds, Leeds Safeguarding Adult Board and Leeds Safeguarding Children Partnership.

Jake, an 18-year-old man died of malnourishment which had occurred over a number of months prior to this death. The exact reason for this is unknown, however medical help had not been sought either by himself or his family members. Several family members were subject to criminal convictions as a result of his death.

The following ongoing learning themes for the Board were identified that could help reduce the risk of such an incident reoccurring.

  • Safeguarding Awareness
  • Professional Curiosity
  • Was not bought approaches, to non-attendance at appointments
  • Neglect
  • Think family, work family
  • Early intervention

Further information about the review is again available on the Safeguarding Adults Review pages of the Board website.

5.2.3  Our Ongoing Safeguarding Adults Reviews

There is one Safeguarding Adults Review ongoing at the time of this report. This concerns Ms I, a young woman with learning disabilities who was subjected to sexual assault by a care worker.  The review is focused on prevention issues and joint working that could mitigate such risks for others in the future.  The review is due to conclude during the Summer of 2023.

5.2.4  Our decisions to not progress reviews

The Care and Support Statutory Guidance requires Board's to report on referrals that were not progressed as Safeguarding Adults Reviews during 2022/23. There were four:
  1. A woman in her early 40s who died in circumstances of limited engagement with services, and who had a history of alcohol dependency and both physical and mental health conditions.  
  2. A woman in her 70s who died shortly after an accident involving her physical care support. Although this was not subsequently identified as the cause of her death.
  3. A man in his 20s who lived in hostel for people experiencing homelessness died in circumstances where there were concerns that he was not taking his prescribed medication as required and that this may have contributed to his death.
  4. A woman in her 60s who experienced severe neglect from her relatives, having previously declined support from certain agencies.

    In each of these cases the specific circumstances were assessed as not meeting the statutory criteria for a Safeguarding Adults Review as set out in Section 44 of the Care Act.

 5.2.5   Our new SAR Sub-group

 The Board introduced a new Safeguarding Adults Review sub-group during 2022 which allows for multi-agency oversight and management of SAR referrals and reviews. The group makes recommendations to the Board as to whether an SAR should be undertaken. The new approach allows for the seeking of individual agency assurances in relation to referrals, even if the decision is not to undertake a Safeguarding Adults Review. This approach has been adopted so as to maximise learning opportunities around best practice.

5.3  Learning through Quality Assurance and Performance

We said we would continue to establish mechanisms to assure the Board of safeguarding arrangements in Leeds.  This work is led on behalf of the Board by the Quality Assurance and Performance sub-group

This has been achieved in a variety of ways during the year, including:

  • Our multi-agency intelligence 'Dashboard' - with contributions from all member agencies, the dashboard provides an overview of safeguarding issues across the city. It helps us understand emerging safeguarding concerns within the city.
  • Our Quality and Impact: Self-assessment – provides an assurance as to how Board Member Organisations have taken forward and embedded both learning and resources developed throughout the year. This includes learning from Safeguarding Adults Reviews, new learning and development resources, new policies and procedures as well as the Board's Ambitions.
  • Our Annual Conversation – a new initiative for 2022/23. The Annual Conversation provides an opportunity to bring partner agencies together to explore a theme that emerged from the self-assessment. On this occasion it was used to explore shared learning about how organisations can embed Board learning into practice. This is leading to further actions during 2023/24 to develop guidance and checklists for organisations.
  • Our multi-agency audit programme - During 2022/23 a multi-agency audit has been undertaken in relation to practice in support of people who self-neglect. This audit process will extend into 2023/24 and involves direct conversations with practitioners about their work to support a person, in a way that both celebrates good practice and identifies learning themes for the partnership.

5.4 Learning and Development

We said we would ensure that practice in Leeds is informed by the Board's mechanisms for learning.  Alongside our learning from the Appreciative inquiry, Safeguarding Adults Reviews and Quality Assurance there are a number of specific projects:

  • Multi-agency training proposals are being explored by a Task & Finish Group. The intention is to always teams that work together to train together, and this might be achieved by the sharing of some training resources across the city.
  • Front-line practitioner survey of over 300 people to provide a temperature check on awareness, knowledge and confidence in working with people who self-neglect.
  • The establishment of a network of learning and development links across organisations, which is proving to be an effective means to disseminate learning and development information and resources. 
  • The Board continues to maintain a Safeguarding Learning and Development Framework.  This framework sets out the elements that should be in place to ensure an organisations workforce is skilled and knowledgeable in safeguarding adults.

6.  Going Forward

6.1  Our Ambitions for 2023 to 2024

The Board's Strategic Plan sets out its objectives for the year ahead. Examples of key priorities are included below, but the full plan is available to read on the Board's website.

Ambition One:  

Develop citizen-led approaches to safeguarding 

Examples of planned work include:

  • Undertake regular consultations about the work of the Board
  • Develop and support our Friends of the Board Network
  • Extend our safeguarding awareness resources

Ambition Two:  

Improve awareness of safeguarding across communities and partner organisations

Examples of planned work include:

  • Work with diverse ethnic communities to inform our approach to promoting awareness
  • Provide safeguarding awareness sessions for community groups in Leeds.
  • Explore multi-agency training options for the city

Ambition Three:  

Develop citywide approaches to safeguarding practice

Examples of planned work include:

  • Take forward our new Leeds Self-neglect Strategy
  • Develop our approach to multi-agency working in Leeds
  • Supporting partners in their work with people at exceptional risk

Ambition Four:

Learn from experience to improve how we work

Examples of planned work include:

  • Continue to develop our quality assurance processes
  • Take forward the learning from Safeguarding Adults Reviews
  • Undertake a multi-agency audit programme to review safeguarding practice in Leeds

[1] Care and Support Statutory Guidance, Section 14.11

[2] Care Act 2014, Section 43(3)

[3]Care Act 2014, Schedule 2

[4] Figures relate to Section 42 and other enquiries commenced during the year

[5] Care and Support Statutory Guidance, Section 14.162 & 14.163