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HSAB publishes Thematic Review into Premature Deaths

Date: Friday, 08th Apr 2022 | Category: HSAB

Herefordshire Safeguarding Adults Board Logo

On Friday 8 April 2022, Herefordshire Safeguarding Adults Board (HSAB) published a Thematic Review into premature deaths.

HSAB has discretion to commission reviews in circumstances where there could be learning from how agencies worked together with respect to an adult with care and support needs, but where it is inconclusive as to whether an individual’s death was the result of abuse or neglect, including self-neglect. HSAB commissioned this thematic review using that discretion having identified a pattern of deaths amongst a cohort of adults with multiple and complex needs, and to learn any lessons to improve the support and services available to others in similar circumstances.

The three statutory Safeguarding Adults partners of the Herefordshire Safeguarding Adults Board are Herefordshire Council, West Mercia Police and NHS Herefordshire and Worcestershire Clinical Commissioning Group. The findings and recommendations from the review have been endorsed by Herefordshire Safeguarding Adults Board.

Ivan Powell, Independent Chair of Herefordshire Safeguarding Adults Board said:

“Herefordshire’s Safeguarding Adults Board is fully committed to ensuring all adults who have care and support needs and particularly those with multiple and complex needs are able to access the right support and services. Where there may be opportunities to improve services and the way that organisations work together we explore this further, share any learning and make changes accordingly.

“This review considered the deaths of six people who had similar complex needs and who were in contact with multiple services. Often organisations did not manage to build relationships with them, key to securing their confidence in and engagement with those services trying to support them.

“I would like to extend my sincere condolences to all of the families affected by this review, and to thank the families of those individuals who spoke to us openly about their loved ones so that we could better understand their life circumstances and their experience of local services.

“We have carefully considered all of the recommendations in the report, and while a number of positive developments have already been made we continue to work towards embedding these across all agencies.”

HSAB Thematic Review - Premature Deaths Adults Reviews


At the request of the Herefordshire Safeguarding Adults Board all media enquiries regarding this Thematic Review will be co-ordinated by Herefordshire Council and should be emailed to