Safeguarding Adults Review Lisa (August 2025)

Lisa was a 43 year old white British woman who completed suicide in April 2023.   She had been known to Mental Health services since 2007 and had a history of substance use disorders and epilepsy.   A note that she left, and her reports in the last weeks, suggest that her life had become intolerable because of demands for money from drug dealers.

A Section 44 referral for a safeguarding adult review (SAR) was submitted as a result of concerns about whether agencies acted in a timely manner to provide a safe service, and whether there was a wider public interest in communicating with relevant statutory agencies, particularly the Police.

You can view the full report and an executive summary here Lisa report v9 FINAL