Below are links to key Safeguarding Adult Review reports and Inquiry Reports, in order of publication with most recent first:

See also Domestic Homicide Review Library (

Safeguarding Adult Reviews

Safeguarding Adults Review Joshua, Lewisham Safeguarding Adults Board (2023) Joshua died aged 35, in 2018. An inquest jury found that system-wide failures contributed to his death.The jury recorded the 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. Actions included a Regulation 28 Report to prevent future deaths issued to the Metropolitan Police Service (MPS) and the London Ambulance Service (LAS).

Safeguarding Adults Review: Whorlton Hall, Durham Safeguarding Adults Partnership (2023) In May 2019, the BBC’s Panorama programme exposed concerns of allegations of physical and psychological abuse of patients residing at Whorlton Hall, which was registered for men and women over the age of 18 with a learning disability and / or who were autistic.

Safeguarding Adults Review: Irene, Salford Safeguarding Adults Board (2022) Irene died in February 2020 aged 71 in the home she shared with her husband Brian. Following her death the post-mortem examination disclosed substantial injuries, only some of which could be accounted for by falls. The pathologist concluded that a significant proportion of her injuries were very likely to have been sustained as a result of physical assault.

Norfolk Safeguarding Adults Board Safeguarding Adults Review (SAR) into the deaths of Joanna, “Jon” and Ben (2021). They had learning disabilities and had been patients at Cawston Park Hospital in Norfolk. They died between April 2018 and July 2020. The review made 13 recommendations for critical system / strategic change.

City and Hackney Safeguarding Adults Board Safeguarding Adult Review into Death of Jo-Jo (2019) The review found the Council breached the Care Act 2014 by failing to properly assess a disabled woman who died following complications related to scabies.

Bournemouth and Poole Safeguarding Adults Board Safeguarding Adult Review and Poole Community Safety Partnership Domestic Homicide Review (2019) into the death of ‘Harry’, aged 22, who had global developmental delay, a moderate learning disability and autistic traits. He was  murdered by two people, one of with whom he had a relationship.

Barking and Dagenham Safeguarding Adults Board (2018) Safeguarding Adults Review Overview Report ‘Drina’ into apparent failure to safeguard Drina, a vulnerable 35 year old Romanian female with learning disabilities.

Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board (2018) Joint Serious Case Review Concerning Sexual Exploitation of Children and Adults with Needs for Care and Support in Newcastle-upon-Tyne

Bristol Safeguarding Adults Board (2018) Safeguarding Adults Review using the Significant Incident Learning Process of the Circumstances concerning Kamil Ahmad and Mr X. Mr Ahmad was murdered by Mr X; they were both tenants in the same housing accommodation which was provided by a charity supporting people with mental health problems.

West Sussex Safeguarding Adults Board (2018) Safeguarding Adult Review In respect of Matthew Bates and Gary Lewis – Mr Bates and Mr Lewis were residents of the same care home in West Sussex. Both have profound learning difficulties, cerebral palsy and are non-ambulant. They were admitted to an A&E Department on the same day, both suffering fractures to a femur.

Bristol – Safer Bristol Partnership (2017): Multi-Agency Learning Review Following The Murder of Bijan Ebrahimi, an Iranian man who was murdered after suffering years of harassment and abuse.

Plymouth Safeguarding Adults Board: Safeguarding Adults Review – Ruth Mitchell (2017) – woman with mental health problems, who died of malnutrition.

Bristol Safeguarding Adults Board (2017) Serious Case Review: Following the murder of a young adult, ‘Melissa’, 18 years old, in October 2014 – which identified problems with transition from children’s to adults’ services, risk assessments, and out of area placements.

Verita (2014) Independent investigation into the death of CS – a report for Southern Health NHS Foundation Trust into the death by drowning of a young man with epilepsy.

West Sussex Safeguarding Adults Board (2014) Orchard View SCR – closure of Southern Cross Healthcare care home for people with old age and dementia; the Coroner found issues of institutional abuse and neglect contributed to the deaths of five residents at their inquests.

South Gloucestershire Safeguarding Adults Board (2012) Winterbourne View – abuse by staff at hospital for adults with autism and learning disabilities.

Warwickshire Safeguarding Adults Partnership (2010) The Murder of Gemma Hayter – murder of a woman with learning disabilities.

Cornwall Adult Protection Committee (2007) The Murder of Steven Hoskins – murder of a man with learning disabilities.

Inquiry Reports

Infected Blood Inquiry

The Independent Inquiry into Child Sexual Abuse

Gosport Independent Panel Report – Inquiry report into deaths at Gosport War Memorial Hospital

Winterbourne View Hospital: Department of Health review and response

Mid Staffordshire NHS Foundation Trust Public Inquiry

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