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 Health Watch 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.
LSAB Annual Report 2023-24
Message from the Independent Chair
“I would firstly like to thank and pay tribute to my predecessor Professor Michael Preston-Shoot. It is clear that I have inherited a well organised and high performing Board following his tenure”.
This is my first year as the independent Chair of the Lewisham Safeguarding Adults Board (SAB) and I would firstly like to thank and pay tribute to my predecessor Professor Michael Preston-Shoot. It is clear that I have inherited a well organised and high performing Board following his tenure.
It has been a genuine pleasure to get to know the members of the Board during this past year, and I want to thank them for their welcome and their hard work. SABs bring together professionals from a range of agencies, and it requires skill, co-operation and a willingness to work together in order for a Board to function effectively. I have witnessed this in the highest order; a commitment to serve the residents of Lewisham to the best possible standards.
The Case Review Sub-Group has met on several occasions during the past year reviewing ten cases and managing four new SAR notifications. The Performance, Audit and Quality Sub-Group launched a new Information Sharing Agreement in January 2024 and also published an
Inter-Agency Escalation Policy. This Sub-Group is key to ensuring that learning from SARs are implemented in practice and it has been strengthened by some new members.
The Board also has excellent representation from people with lived experience. I am grateful for their willingness to serve, be heard, and to hold the Board to account for its actions.
Our understanding of domestic violence and the significant impact it has on women and girls continues to develop and this is why the Board has recommitted to making this a priority for 2024-25. We need to support the work on prevention and take urgent action to reduce the impact of this type of abuse.
We are also seeing a significant rise in the scale and type of frauds in society. This is something that affects us all, but it is the vulnerable who are most at risk as they are often less able to spot this. We co-produced an easy read guidance leaflet along with Lewisham Speaking Up and their service users. This will support the efforts to help prevent this type of crime within our local community.
This report also presents our priorities for the coming year. They are ambitious, and rightly so, as we continue to do all we can to help build safer and more resilient communities.
Finally, I would like to thank the Board’s Business Unit Team. They are simply amazing in delivering their significant administrative workload and keeping the SABs business moving forward by managing a wide range of actions plans. They also co-ordinate and deliver training, lead the work on policy development, along with the massive undertaking of managing the caseload of Safeguarding Adults Reviews.
Thank you.
Professor Keith Brown
Summary of Delivery in 2023-24
The Board continued to oversee the delivery of its strategic aims and objectives.
Key areas of work included:
Safeguarding Adults Reviews (SARs)
The Board continues to be busy with several notifications being submitted throughout the year. Details of the two published SARs from the reporting period and the Second National Analysis can be found below.
Learning and Development
The Board delivered over 40 learning activities during the last 12 months reaching a record number of participants. This included a focus on responding to sexual violence and awareness of neurodiversity, as well as a transitional safeguarding workshop which staff from the Business Unit helped to arrange.
Community Engagement
There were a number of events that were designed and delivered to engage members of the public and citizens who have lived experience of abuse and neglect. This included involvement with the Board’s development session. The feedback is used to help ensure that strategic priorities are relevant and to promote information to help with prevention.
Think Family
This was one of the key objectives for 2023-24 and involved a detailed project to develop some new guidance for the borough on this subject, as well as further toolkits to help support practitioners.
Self-Neglect
Important work continued throughout the year to develop new policy and procedures.
Statutory Advocacy
Advocacy is designed to empower people to have a voice if they are having difficulties taking part in the decision-making processes linked to health and social care matters.
This could be for a variety of reasons, including having a learning disability, mental or physical health issues, or being very elderly or frail.
“No decision about me, without me”.
Unfortunately this can be overlooked sometimes and we have relatively low use of our statutory advocacy services compared to other local boroughs:
The local authority can refer adults for advocacy support for any stage, of any of the following:
- s.9 Needs Assessment.
- s.10 Carer’s Assessment.
- s.25 The preparation of a Care and Support Plan or Support Plan.
- s.27 A review of Care and Support Plan or Support Plan.
- s.42 Safeguarding Enquiry.
- s.44 Safeguarding Adults Review (SAR).
Case Studies and Partners Work (All case studies have been anonymised.)
Metropolitan Police Service
Andrew first came to the attention of the police as a missing person several years ago and since then he has been reported missing multiple times. Andrew’s family have relayed their fears to Officers regarding his complex medical conditions and
other vulnerabilities. There have been occasions when Andrew has been found in the company of individuals known to have a criminal history, including drug dealers.
Andrew’s mental capacity is being reviewed and a therapeutic residential placement is being considered. It is hoped that a therapeutic setting, with the assistance of a chaperone in the community, will encourage Andrew to actively engage in key work sessions that could positively impact on improving his skills to enable him to live safely and independently in supported accommodation.
The Lewisham Safeguarding Adults Board is currently leading on developing some tri-borough guidance to help improve the response to missing adults episodes.
NHS South East London (SEL) Integrated Care Board (ICB)
The SEL ICB Adult and Child Safeguarding Policy was refreshed by the Lewisham team in the last year and a Safeguarding Supervision Policy has been developed.
The SEL Safeguarding Team contributed to the presentation at the assessment panel in March 2024 which supported Lewisham in its re-accreditation as a Borough of Sanctuary. To support this there has been an enhanced primary care approach for asylum seekers in the Home Office provided accommodation in Lewisham, to identify and mitigate any health or safeguarding concerns. The team also continued to provide support to GP practices and third sector organisations who have queries in relation to complex safeguarding cases, and an audit of GP safeguarding procedures has also taken place.
Following a request by the LSAB Board a review and audit of fire policies and procedures in older people’s care homes was conducted, including observations of mock fire emergency situations. 100% of the recommendations from this review have been completed by care homes. SEL ICB staff continue to support the delivery of the Learning Disability Mortality Review (LeDeR) programme in Lewisham, which reports to the Lewisham Learning Disability & Autism Health Stakeholder group.
South London & Maudsley NHS Foundation Trust (SLaM)
Staff at SLaM have been working hard over the last 12 months to restructure and refresh the way safeguarding is managed in the trust. This has resulted in the successful recruitment of a number of new staff members into a central safeguarding team, with a lead in each borough, and specialist domestic abuse and exploitation workers. A new set of operating procedures has also been developed and safeguarding procedures updated.
Lewisham Council - Adult Social Care (ASC)
Adult A had a diagnosis of cognitive impairment and other morbidities. The case was discussed at a multi-agency case conference, and a Safeguarding Enquiry commenced, due to concerns that a family member was making inappropriate decisions about care arrangements. The adult was engaged and a referral to the statutory advocacy provider was made, before a transfer to a hospital outside of the borough. Following an assessment of mental capacity related to discharge destination, and further discussions, the adult left hospital into the care of his spouse with a relevant and comprehensive package of care and wider facilitated support.
Considering the decline in the adult’s cognitive ability and the fact this was unlikely to improve due to a diagnosis of vascular dementia. The adult would continue to be at risk of further neglect, acts of omission, and or psychological abuse. Despite this the Safeguarding Enquiry was closed at the initial stage as requested by the adult and their spouse (Making Safeguarding Personal), although the allocated Social Worker continues to monitor the case and review the package of care.
During the last 12 months developmental activities include:
- Extensive Safeguarding Enquiries in relation to some care homes in the borough.
- Delivery of action plans related to safeguarding audits.
- Establishment of a domestic abuse specialist worker’s role and improved joint working with the domestic abuse service provider (Refuge - Athena).
- ASC wide review of safeguarding processes and practice.
- Improved ways of working in the Multi-Agency Safeguarding Hub (MaSH).
Lewisham and Greenwich NHS Trust (LGT)
Simon has attended the Emergency Department (ED) at the Trust 49 times in the last two years. He usually attends in an intoxicated state. Members of the public often call the London Ambulance Service for him. At times, members of LGT staff have brought Simon into the ED when he has been found collapsed outside the hospital. He has often attended with injuries, sometimes following an assault. He has also attended with chest infections and chest pain. He has often been doubly incontinent at presentation he is often verbally aggressive to staff but has never been violent.
Simon often leaves the Emergency Departments before his assessment is complete.
Simon has also attended multiple hospitals across London in the same timeframe, and has several underlying and serious health conditions. Simon told a member of the adult safeguarding team that he was street homeless following childhood abuse and criminality, but that he does now have a room at a supported housing placement.
LGT staff have tried to refer Simon to the local authority by using safeguarding procedures, but as yet this has been unsuccessful as Simon is choosing not to engage (this case has been escalated). Staff have also referred Simon to the Lewisham High Intensity User Panel at which patients are discussed to make safety plans as well as linking them in with appropriate local services.
Despite the great work by LGT staff there is still a need to improve the multi-agency response to cases like this, and consider how best to support chronic dependent drinkers like Simon, where there are also obvious safeguarding risks.
Statutory reviews are now more closely monitored and tracked, and new ways of working implemented to strengthen individual supervision sessions for staff.
Learning, Training and Development
As outlined below the number of learning events being provided by the Board and therefore the numbers of participants has grown significantly over the last 4-5 years.
This has been strongly influenced by Covid-19 and the move to online working, and although there is a growing appetite from some for in-person activities, these are not as well attended as online events and are difficult to ‘sell out’ with high drop out rates being very common. The maximum capacity for arranging events based on available resources is also now being reached as illustrated by the graphs above.
The use of the LSAB website has almost doubled in the last 4 years which coincides with the launch of the local Adult Safeguarding Pathway in 2021, although growth is now slowing as we probably start to maximise its potential reach.
National Adult Safeguarding Awareness Week November 2023
The Board supported (and helped to plan) the programme of online activities that was delivered across London between 20 and 24 November 2023, which included a main conference which linked with in-person hubs that had been established in some boroughs. 2,000 professionals attended the online programme that covered a wide range of topics. The same approach will also be used in 2024, although it is hoped the numbers that attend will be significantly higher.
There were also a series of three in-person ‘listen and learn’ workshops delivered in Lewisham during that week which were designed to ensure that the voice of local citizen’s and professionals informs the work of the Board. These were really well received and attended by a total of 70 people.
Communication and Engagement
SCAMS Leaflet 
The Board were delighted to work with Lewisham Speaking Up again on this new easy read leaflet that was co-produced with their service users and published in the early part of 2024.
It is very detailed and covers all of the information that members of the public need to be able to identify the different types of SCAMS, how this can happen, and who to approach for advice and support.
Although this is an easy read document and aimed at adults living with a learning disability, it is a useful resource that can be used by anyone and we strongly recommend this.
Lewisham Safeguarding Adults Board - Scams Easy Read Booklet
Housing Summit
The Board facilitated the 2nd Housing Related Safeguarding Summit on 14 December 2023 following on the success of the first the previous year which is
designed to bring professionals together from across the housing sector, along with health, social care and other colleagues to discuss safeguarding related matters. This was attended by 44 professionals with the highlight being the video of participants of the hoarding support group that had being running as a trial in Lewisham during 2023.
View the video: Lewisham Hoarding Support Group 2023
Think Family 
The Board has been working closely with the Lewisham Safeguarding Children Partnership on this subject which has resulted in the Think Family Practice Guidance being published, alongside a Working with Fathers and Carers Toolkit.
Lewisham Safeguarding Adults Board - Information for Professionals
This important area of work will continue on into 2024-25.
LSAB Social Media
Between 2019 and 2024 we’ve had circa 220,000 ‘impressions’ on Twitter.
We will keep this account but focus on Instagram now.
We have recently launched an Instagram account and will commit as much time as we can to try to reach a wider audience across Lewisham.
Safeguarding Information 2023-24
Table 1: Concluded Section 42 Enquiries 2023-24: Types of Abuse
Table 2: Lewisham Crime Context: 2023-24
Table 3: Age Demographics in Lewisham: Census Data 2021
Table 4: Concluded s.42 Enquiries: Times Series 2017-18 to 2023-24
Safeguarding Adults Reviews (SARs)
The period in scope for this review was 01.09.17 to 09.03.18, which is the date Joshua died. There were lengthy delays to the review largely due to repeated investigations by the Independent Office for Police Conduct (IOPC).
Joshua was a Black Caribbean man who first came into contact with mental health services in 2002, at the age of 19. He was a patient of Mental Health Forensic Services since 2006 and of the Community Mental Health Team since 2014. Joshua had nine admissions to hospital under the Mental Health Act (MHA)1983.
At the Coroner’s inquest the jury found system-wide failures contributed to his death. A Regulation 28 Report to prevent future deaths was issued to the Metropolitan Police Service and the London Ambulance Service. The jury recorded the medical cause of death as Acute Behavioural Disturbance (ABD) (in a relapse of schizophrenia) leading to exhaustion and cardiac arrest, contributed by restraint struggle, and being walked.
A key outcome from the case was that agencies should review relevant training and policies to strengthen anti-racist perspectives and to include the involvement of people with lived experience and their families and third sector organisations.
Arthur SAR Published 10 November 2023
Arthur was an 81-year-old Black British Caribbean man who lived in Lewisham with his wife, who was also his carer. In September 2021, Arthur was unlawfully killed by his son, ‘Anthony’ [pseudonym]. Arthur had physical disabilities including sight impairment.
Anthony lived alone in a flat provided by the local authority. He had been known to the police since the 1990’s and there had an escalating pattern of anti-social behaviour in his own home prior to the incident. Anthony also had a diagnosis of Treatment
Resistant Schizophrenia and had been known to mental health services since 2000.
Practitioners need to be aware of, and professionally curious about, familial abuse, with recognition of the hidden nature of older people who experience such abuse. Any concerns of familial abuse should be responded to appropriately including risk assessment, safeguarding procedures and referral to support services.
All of the published SARs in Lewisham can be read here:
Lewisham Safeguarding Adults Board - Safeguarding Adults Reviews
Adult 01 (Unpublished)
This review is being conducted in two parts due to ongoing criminal investigations. Practitioners have not been directly involved so far to prevent any potential prejudice of the police investigation, although this has still allowed the Board to share the initial and key learning points with agencies. The second part will be concluded once these parallel proceedings allow, and hopefully lead to the full report being published into the public domain. The case involves serious neglect and a focus on mental capacity.
Second National SAR Analysis 2019 to 2023
The second national analysis of Safeguarding Adults Reviews (SARs) in England was funded by Partners in Care and Health, supported by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS).
Its purpose was to identify priorities for sector-led improvement as a result of learning from SARs completed between 2019 and 2023.
The analysis builds on the findings of the first national analysis, published in 2020, which considered learning from SARs completed between 2017 and 2019. Taken together, the analyses provide a significant knowledge base about adult safeguarding in England across all types of abuse and neglect. They highlight both the shifts that have taken place and the challenges that endure.
- 652 Safeguarding Adults Reviews (SARs) were considered.
- 1075 people were affected - 861 where there was specific detail.
- 128 Safeguarding Adults Board (SABs) involved (100%).
- 8 SABs had not published a SAR in this period.
Some reviews will have considered multiple types of abuse.
The data highlights that self-neglect continues to be a high risk issue as only 7% of concluded Safeguarding Enquiries in 2022-23 in England were for this subject.
The most prominent practice shortcomings were:
- Risk assessment and management.
- Attention to mental capacity.
- Recognition of the abuse or neglect.
These trends across England are mirrored in the findings from Safeguarding Adults Reviews in Lewisham.
Work of the Sub-Groups
Case Review Sub-Group
The Sub-Group oversees Safeguarding Adults Review (SAR) processes locally, and is now led by Joan Hutton the Director of Operations for Adult Social Care.
The group met 7 times during 2023-24 and considered or monitored 10 cases throughout the year, including 4 new SAR Notifications. A previously agreed review which had commenced was halted after it was agreed that no further learning could be extracted following on from a Learning Disability Mortality Review (LeDeR)involving the same adult.
The Board’s SAR Policy and Procedures October 2023 were reviewed during the reporting period taking into account new draft guidance produced by the London Safeguarding Adults Board.
Lewisham Modern Slavery and Human Trafficking (MSHT) Network
The Board continues to administrate and support the delivery of this multi-agency group which meets on a quarterly basis.
On 23 January 2024 the network held an online conference attended by 100 delegates including a speaker with lived experience who reinforced the good work from professionals she had benefited from in their approach:
“They believed in me, and saw me as a person and not just another case”.
Useful information on this subject can be accessed here: Lewisham Safeguarding Adults Board -Modern Slavery & Human Trafficking
A new learning resource was also published in October 2023 as an alternative to e-learning: Modern Slavery Awareness Workbook and there is also
Regular training available on this subject:
Lewisham Safeguarding Adults Board - Learning Zone
Performance, Audit and Quality Sub-Group
The group continued to meet throughout the year with a busy work programme. Most notably the Board published a new Information Sharing Agreement in January 2024 which is the first time this has been created specifically and uniquely for Lewisham after several years being linked in with a London wide agreement. This was a significant project and is a best practice document that any agency in the borough can refer to.
There is a dedicated webpage on this subject which is very useful: Lewisham Safeguarding Adults Board - Information Sharing
The Board also published a new Inter Agency Escalation Policy in July 2023 and Guidance on Improving our Approach to
Adult and Family Engagement in Jan 2024:
Lewisham Safeguarding Adults Board - Policy and Procedures
A Mental Capacity Audit was conducted in October 2023 which will result in an update to procedures across adult social care and the two local NHS Trusts.
Safeguarding audits have also been undertaken to help prepare for the Care Quality Commission’s (CQC) new inspection regime, and more generally to help partners ensure they have the right focus and priorities.
Self-Neglect Task and Finish Group
This group met throughout the year to lead the work on the consultation and development of the Multi-Agency Self Neglect Policy, Practice Guidance and Procedures. These were being finalised as we approached the end of the period. The new procedures will include the implementation of a new High Risk Panel that will consider the most serious cases in the borough.
Strategic Business Plan 2024-25
In line with the five priority areas there are a total of 19 Actions that are planned for 2024-25. This includes the development of new local guidance on the subject of Adult Sexual Exploitation (ASE); a continued focus on Out of Borough Placements; events designed to raise the profile of missing adults and homelessness; and the creation of a new training course for professional curiosity which is a feature in most SARs.
Full details can be read here:
Lewisham Safeguarding Adults Board - Partnership Compact and Strategic Business Plan 2024-2025
Download a copy of the LSAB Annual Report 2023-2024
Download a copy of the LSAB Annual Report 2022-2023
Download a copy of the LSAB Annual Report 2021-2022
Download a copy of the LSAB Annual Report 2020-2021
Download a copy of the LSAB Annual Report 2019-2020
Download a copy of the LSAB Annual Report 2018-2019