Page 3 - Adult C Overview Report - FINAL

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1. INTRODUCTION AND CIRCUMSTANCES LEADING TO THE REVIEW

1.1. Adult C was a 30-year-old lady who died following cardiac arrest after diagnosis and
treatment for pneumonia. Adult C was a longstanding alcoholic who showed some signs of
wanting to reduce her alcohol consumption. Adult C was known to have been in an abusive
relationship with reports of injuries from both her partner and her ex father in law as well as
others. Adult C was also considered to be a perpetrator of physical violence against her
partner and other adults. Adult C was known to many agencies as a result of her alcoholism
and the abuse she suffered. On the date of her death, it was her partner who called an

ambulance; her ex father in law was also present. They were originally arrested on suspicion
of the murder of Adult C, but her death was later found to be from physical health causes. An
inquest confirmed death by natural causes.

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) and other reviews. Full Terms of Reference, rationale
for the scope and methodology of the review etc. for this Learning Lessons Review (LLR) can
be found in Appendix 1.

2.2. This review takes into account interagency involvement covering the six months prior to the
date of Adult C’s death. This period covers a timeframe where there is likely to be learning
within contemporary systems and multiagency working as opposed to identifying learning
from historical systems that may have already changed. Key background information will also
form part of the review that will inform the more contemporary elements of Adult C’s
journey.

3. FAMILY ENGAGEMENT

3.1. A key part of undertaking a LLR is to gather the views of the family and share findings with
them. Contact by letter was made with Adult C’s partner and mother. No response was
received from Adult C’s mother. The Board Manager and the Author met with Adult C’s
partner (Adult 1) following the second workshop. His views have been incorporated
throughout the report as appropriate.

4. BACKGROUND PRIOR TO SCOPING PERIOD

4.1. Agencies report that Adult C had stated that she had enjoyed school and went to college to

study cookery. It was whilst at college that she met her previous partner. In her interactions

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