Page 3 - TSAB Adult B FINAL (1)

This document was classified as: OFFICIAL

1. INTRODUCTION AND CIRCUMSTANCES LEADING TO THE REVIEW

1.1. Josh was a young man in his late twenties who was homeless and had diabetes. He had taken multiple
overdoses of his insulin which resulted in a number of admissions to hospital due to self-neglect of his
diabetes and misuse of medication. The taking of too much insulin (or not enough) leads to life
threatening emergencies. As a result of a significant overdose of insulin, Josh suffered a permanent
and life changing brain injury and it was believed that he was likely to have additional care and
support needs for the rest of his life. Josh, however passed away unexpectedly in hospital just over
three months later.

2. METHODOLOGY AND SCOPE

2.1. The Care Act 2014 states that a Safeguarding Adults Board (SAB) must undertake reviews of serious
cases in specified circumstances. Section 44 of the Care Act 2014 sets out the criteria for a
Safeguarding Adults Review (SAR). Full Terms of Reference, rationale for the scope and methodology
of the review etc. for this SAR can be found in Appendix 1.

2.2. This review takes into account interagency involvement covering the six months prior to the date that
Josh suffered the brain injury. This is the period that covers identification of a considerable number of
contacts with agencies. Key background information will also form part of the review that will inform
the more contemporary elements of Josh’s journey.

3. FAMILY ENGAGEMENT

3.1. A key part of undertaking a SAR is to gather the views of the family and share findings with them prior
to publication. It is documented that Josh was estranged from his family. TSAB made contact with a
sister by letter via the coroner’s office. A reply was received following after some time. The author
made contact with the nominated family member who is a cousin of Josh’s. The author and Board
Manager met with Josh’s two sisters, his cousin and Aunt and Uncle.

4. BACKGROUND PRIOR TO SCOPING PERIOD

4.1. Josh had been known to services at a very young age. His formative years proved difficult with
parental separation at 13 years old having an impact on him. He told mental health teams that he
turned to substances to block out emotions. Historical information recorded in children’s social care
records suggests early substance misuse leading to anti-social behaviour and assaults within the
family both from Josh and to Josh by his parents. This led to his mother requesting that he was taken
into care. Josh described this event as being so that his mother could meet someone else. Family
reflected that Josh and his mother had a very volatile relationship. A further assault on mother left
Josh remanded to Local Authority care.

4.2. During a period of time being cared for by his Aunt and Uncle, Josh went back to school and did his
GCSEs. Whilst this was quite a successful arrangement for a time, there was no legal agreement to
this, and Josh chose to go back to live with his mother for a while.

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