Thematic Safeguarding Adults Review (August 2025)
This thematic Safeguarding Adult Review (SAR) concerns three adults, Max, Claire and Iliya who died between October 2022 and July 2023
Max
Max was a Black British man of African-Caribbean origin who was 60 years old when he died. Max lived alone in a council flat on the ground floor. Max had a diagnosis of schizophrenia and was under the care of the Community Team of Oxleas NHS Foundation Trust (Oxleas Mental Health Trust Community Team). Max had been detained under the Mental Health Act 1983 on several occasions, both formally and informally. Max was identified as non-compliant with medication and severely self-neglecting, which included poor food and fluid intake and poor personal hygiene. Max also used cocaine, although the extent of this is not known. A Mental Health Act 1983 assessment was attempted on 11th July 2023 and police officers entered Max’s flat but could find no one there. Max was reported as a missing person but was found deceased in a wardrobe at his home on 20th July 2023. Max’s cause of death could not be determined.
Claire
Claire was a white British woman who was 39 years old when she died. Claire experienced low mood, anxiety and agoraphobia and was diagnosed with Emotionally Unstable Personality Disorder. Claire also had a history of alcohol and substance misuse and developed a nasal deformity due to her cocaine use. Claire had also been the victim of domestic abuse, including physical assault, for which her partner was jailed. Claire appeared to self-neglect, with poor self-care and her flat was unclean and untidy. Claire had told Oxleas Mental Health Trust Community Team that she had agoraphobia. Claire’s mother reported to the Community Team that Claire was self-neglecting and needed to be visited by services at home since Claire would not leave her home. Claire did not attend some medical appointments for her physical and mental health needs. Claire died at home in October 2022, the day before her circumstances were to be discussed at a multi-disciplinary team. Claire’s cause of death was chronic relapsing pancreatitis and micronodular cirrhosis. Chronic alcohol abuse contributed to the cause of death.
Iliya
Iliya was 31 years old when he died. Iliya was born, and had lived, in Bulgaria and now lived in the UK with his mother and father, who acted as his carers. It appears that prior to registering with a local GP practice in the UK Iliya had a pre-existing diagnosis of paranoid schizophrenia. Iliya spoke little English and communication with Iliya and his mother required a Bulgarian interpreter.
Iliya’s mother reported that Iliya’s alcohol intake was “excessive” and that he would not engage with mental health services for fear of being sectioned. Iliya’s mother explained that Iliya had experienced a traumatic admission to psychiatric care in Bulgaria. On 27th April 2023 and 30th May 2023, attempts were made by Iliya’s GP and ambulance crews to persuade Iliya to accept treatment in hospital for liver disease. However, Iliya refused and was considered by ambulance crews to have the mental capacity to do this. However, after a third attempt on 6th June 2023. Iliya was admitted but died in hospital on 27th June 2023. Iliya’s cause of death was multi-organ failure, the underlying cause of which was alcoholic liver failure and schizophrenia.
Whilst their individual circumstances differed, Max, Claire and Iliya had life experiences in common. These included mental health needs, substance use (alcohol and / or drugs), self-neglect and trauma in adult life.
You can access the full report including an executive summary here Self-neglect Thematic Review FINAL