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Lewisham Safeguarding Adults Board

Annual Reports

LSAB Annual Report 2019-2020 LSAB Annual Report Front Cover 2019-2020

Message from the Independent Chair

“I write this introduction in the long shadow of the pandemic, the gradual easing of the lockdown and the havoc wrought on people’s lives by COVID-19”.

I must begin by acknowledging the resilience, commitment, determination and courage demonstrated by health and social care workers, uniform officers, wardens and other professionals. The care and support they have offered, and their professionalism in the face of risk, loss, fear and anxiety, has been outstanding. I must also comment on the community response, those neighbours, community organisations and faith groups who have looked out for, and looked after others. 

I write also in the context of Black Lives Matter. I know that all members of Lewisham SAB, and the staff they represent, have demonstrated commitment to counteract discrimination and oppression, to recognise and challenge unconscious bias, and to promote equality. As Black Lives Matters demonstrates, there is more to do and the SAB must renew its commitment to equality in its strategic plan.

The Coronavirus Act 2020 did not alter the adult safeguarding provisions and protections in the Care Act 2014. The SAB has therefore continued to exercise oversight over  adult safeguarding, whilst mindful of the pressure that health and social care providers have been and continue to be under. The SAB has been reviewing how services have been responding to the challenges that the virus has created. There are clearly lessons that will have to be learned in the coming months about the response to the pandemic, locally, regionally and nationally.

This year’s annual report is shorter than usual, mindful not to place additional burdens on partner agencies. Thus, we have not asked partner agencies to provide examples of positive practice this year. We have included, as statutory guidance requires, information about completed Safeguarding Adults Reviews (SARs). Just outside the timeframe for this annual report (June 2020), the SAB has published three further SARs, which may be found on the Board’s web pages. Next year’s Annual Report will provide an update on the actions taken to implement the recommendations from these reviews. 

We have maintained close oversight on arrangements led by the CCG and the Local Authority to reduce the incidence of pressure ulcers. We maintain a close focus on reviews of deaths of learning disabled people, and on learning from the deaths of people experiencing homelessness and/or substance misuse. 

There is, of course, more to do and more that should be done in the name of improvement. We would welcome your feedback. We thank you for the work you do to keep our communities safe and to respond to the needs of adults at risk of abuse and neglect. Finally, I would to express my appreciation for the work of SAB officers, Martin Crow, Vicki Williams and Tiana Mathurine.

Photo of Professor Michael Preston-Shoot - Independent Chair - Lewisham Safeguarding Adults Board

Professor Michael Preston-Shoot

Independent Chair

Key Outcomes in 2019-20 

April to June 2019 2
  • Board’s Annual Conference was delivered at Goldsmiths College.
  • Board’s Self Neglect & Hoarding Policy and Procedures were agreed for publication. *
  • Board purchased the Electronic Case Record (ECR) system for use with Safeguarding Adults Reviews (SARs).
  • Learning Event for the Michael Thompson SAR was delivered.
July to sept 2019 2
  • Board’s Compact and Strategic Business Plan 2019-20 was agreed.  
  • Board’s Communication and Engagement Strategy was published (see page 3). *
  • External Section 42 Audit was conducted. *
  • Pan London Safeguarding Audit (SARAT) was completed in Lewisham by Board partners.
  • Review of Out of Borough Placements (linked to the Whorlton Hall serious incident) was conducted. *
Oct to Dec 2019 2
  • Board’s Learning, Training and Development Strategy was approved. *
  • The first of 4 Networking and Safeguarding Champions events was delivered to coincide with National Hate Crime Awareness Week, supported by the Council and Metropolitan Police. *
  • The first meeting of the Board’s Performance, Audit and Quality Sub-Group was held. *
  • Two Hoarding Awareness Workshops were delivered in support of the Policy and Procedures published in April. *
  • Trial of a new Pan London Audit Tool was completed by South London and Maudsley NHS Foundation Trust.
Jan to March 2020 2
  • The Board’s Prevention Audit commenced. *
  • 2 Practitioner Events were delivered as part of ongoing SARs.    
  • The second of 4 Networking and Safeguarding Champions event was delivered to coincide with National Sexual Abuse and Violence Awareness Week. *
  • Domestic Abuse and Violence Summit Task and Finish Group was set up jointly with Lewisham Safeguarding Children Partnership (‘Whole Family’ approach). *
  • The Board approved the creation of a local Modern Slavery Network - supported by the LSAB Business Unit. *
  • Joint Protocol with Lewisham Safeguarding Children Partnership was approved (‘Whole Family’ approach). *

*Objectives from the Strategic Business Plan 2019-20 

Communication and Engagement (CE) Strategy Outcomes

The Board’s CE Strategy was agreed in July 2019.The targets were set for 12 months, so were still being delivered beyond the timeline of this report.

Communication & Engagment Strategy outcomes

Safeguarding Information

Overview 2019-20

A lack of reporting emanating from the adult’s own home may be linked to a possible lack of engagement with and from some communities. There are high numbers of domestic abuse incidents reported to Police in the Borough, but very few that are being investigated through Local Authority led adult safeguarding enquiries (4%). 

Overview 2019-2020

 Overview part 3


Safeguarding Adults Reviews

Safeguarding Adults Boards (SABs) must arrange a SAR when an adult dies either as a result of abuse or neglect, known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. (Care Act Statutory Guidance 14.162)

The Case Review Sub-Group

The Sub-Group manages and oversees the Safeguarding Adults Review (SAR)process locally, and is led by the Board’s Independent Chair Professor Michael Preston-Shoot.

The group met 7 times throughout the year and included membership from Lewisham Borough Council, the Metropolitan Police, Lewisham Clinical Commissioning Group, CCG) Lewisham & Greenwich NHS Trust and South London and Maudsley NHS Foundation Trust.

A significant amount of work was overseen by the group, and in addition to the cases outlined in this section of the report, other non-statutory reviews and reports were also considered and monitored.

This included the local annual reports for The Learning Disability Mortality Review Programme (LeDeR), and Drug and Alcohol Related Deaths.

SAR Notifications

The Board received and considered 9 new SAR Notifications during 2019-20, which resulted in 4 new SARs commencing, with one decision still pending due to parallel processes.

In total 14 cases were considered and or monitored by the Sub-Group throughout the reporting period.

Cedric Skyers SAR

The Cedric Skyers SAR was published in 2017, but the local CCG and London Borough of Lewisham Council issued

Guidelines on Risk Assessment for Smoking in Care Homes in September 2019, which is linked to the action plan for this review. This important guidance and the review can be viewed here:

 “Initiate joint work with the London Fire Brigade and care providers in the Borough on risk assessment – specifically to include fire, smoking, immobility, wheelchair use and first aid – to establish mutually clear and consistent standards and expectations”.

SAR Themes and Demographics

The data is based on the 14 serious cases that were considered during 2019-20:

SAR gender image

SAR ethnicity imageAnalysis

The three most common types of abuse linked to the cases considered by the SAR Sub-Group were:

  1. Neglect and Acts of Omission (55% of cases)
  2. Physical Abuse
  3. Self-Neglect.

This is not surprising as 1& 2 are the most prevalent forms of abuse identified in Lewisham, and approximately half of all SARs nationally are linked to the subject of Self-Neglect (national SAR library - Social Care Institute for Excellence).

The local data also reinforces the ongoing need for professional development in relation to Mental Capacity, which is also a very common feature in many SARs across the country.

The demographic information needs to be examined in greater detail across a longer period of time. This should also be compared with other relevant sources of information to ascertain if there are any identifiable inequalities in the most serious cases, although the age and gender data linked to the care issues of Mental Capacity, Mental ill-Health and Substance Misuse suggests a local trend. 

Work of the Sub-Groups

Case Review Sub-Group                          

The work of this group is outlined above.

Housing Sub-Group

The group continued to meet quarterly throughout the year, bringing a wider range of agencies and providers together.

The scope of the group was expanded to work jointly with the Lewisham Safeguarding Children Partnership (LSCP), which is in line with the Board’s strategic Partnership Aim to adopt a ‘whole family’ approach to safeguarding.

The group helped to develop the Board’s Single Agency Adult Safeguarding Policy.  

Performance, Audit and Quality Sub-Group

This group was formed in September 2019 to oversee the collective performance of partner agencies in the Borough in relation to protecting adults at risk of abuse and neglect.

The group meets quarterly and has worked to establish a set of 5 Performance Indicators (P.i’s). These are benchmarked against national averages outlined in the NHS Digital Safeguarding Adults Collection (SAC Return), which is collated and published annually.  

The group also developed the Board’s Prevention Audit and oversaw the Pan London adult safeguarding audits in Lewisham.

Liberty Protection Safeguards Task and Finish Group

This group was set up during the year to consider the strategic issues across Lewisham in relation to the transition from the existing Deprivation of Liberty Safeguards provisions (DoLS), to the new Liberty Protection Safeguards (LPS) scheme under the Mental Capacity Amendment Act.

The group was overseeing the link between the development of local arrangements and those sub-regionally across South East London, as well helping to plan training sessions and think about the operational implications linked to implementing new policies and procedures.

There was an initial delay with the publication of the national statutory guidance for LPS, before COVID-19, which has meant the programme is likely to be pushed back until 2022.

Domestic Abuse and Violence Summit Task and Finish Group

This group was established jointly with the LSCP (‘whole family’ approach) and Violence Against Women and Girls Forum (VAWG), in response to the Board’s

Training Needs Analysis in Oct 2019, that indicated that the Board’s annual conference for 2020 should be focussed on this subject.

This event was originally planned for 25 June 2020, but has been postponed due to COVID-19.

Business Plan 2020-21 on a Page

Iamge of LSAB vision statement

 Image of LSAB priorities

Prevention Aim shape


  1. Further improve public and professional awareness:

        - review the Board’s Communication and Engagement Strategy.

    2. Expand the Board’s Learning, Training and Development Strategy:

        - develop Foundation Level learning.

        - use the findings from SARs published in Lewisham to inform delivery.

    3. Deliver the findings from the Prevention Audit, including a full review of Advocacy Services.

Accountability aim shape


  1. Implement a refreshed Adult Safeguarding Pathway including links to the delivery of an adult Multi-Agency Safeguarding Hub (MaSH), improving consistency of approach and helping remove barriers to reporting abuse.
  2. Expand data analysis to closely examine ethnicity related information.
  3. Use the information from the National SAR Analysis (August 2020) to inform audit and review processes, leading to sector led improvements.
Partnership Aim shape


  1. Develop ‘Trauma Informed’ leadership and practice.                                                                          
  2. Work towards reducing racial disparity and disproportionality: - delivering effective whole community engagement.
  3. Further embed the ‘Think Family’ approach to safeguarding, working effectively with the Local safeguarding Children Partnership, Health and Wellbeing Board and Safer Lewisham Partnership.

As this framework was only established in July 2019 the core has remained unchanged from 2019-20, although the objectives have been updated in line with the intelligence and feedback that has been generated over the last 12 months.

Safeguarding is everyones business all of have a role to play

Download a copy of the LSAB Annual Report 2019-2020

Download a copy of LSAB Annual Report 2018-2019

Annual Reports

The Care Act 2014 requires each Safeguarding Adults Board (SAB) to publish an annual report. 

The Care Act (Schedule 2.4 (1) a–g) defines the minimum content of an annual report:

As soon as is feasible after the end of each financial year, a SAB must publish a report on:

What it has done during that year to achieve its objective,

What it has done during that year to implement its strategy,

What each member has done during that year to implement the strategy,

The findings of the reviews arranged by it under section 44 (safeguarding adults reviews) which have concluded in that year (whether or not they began in that year),

The reviews arranged by it under that section which are ongoing at the end of that year (whether or not they began in that year),

What it has done during that year to implement the findings of reviews arranged by it under that section, and

Where it decides during that year not to implement a finding of a review arranged by it under that section, the reasons for its decision.

The performance of member agencies and how effectively, or otherwise, they are working together should be included in the report.

The annual report must be sent to:

The Chief Executive and leader of the local authority which established the SAB,

Any local policing body that is required to sit on the SAB,

The local Healthwatch organisation,

The chair of the local health and wellbeing board.

Annual reports should form the basis for the consultation on the strategic plan for the coming year.

A SAB should seek assurance from its members that the annual report has been considered within their internal governance processes.


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