Cases of neglect highlighted in annual report by the West of Berkshire Safeguarding Adults Partnership Board

Posted: 15th February 2022

Six cases of neglect, including that of an old man being left soaked in urine and covered in bruises and pressure sores, have been revealed by health officials in Berkshire.

The deep dive investigations were ordered by West of Berkshire Safeguarding Adults Partnership Board (SAPB).

They show significant failings of different agencies, resulting in care of some of the most vulnerable adults in the district falling through the gaps.

In its annual report the SAPB says there has been a 50% increase in the number of safeguarding concerns across West Berkshire, Reading and Wokingham in the past year.

Of those, 58% of enquires were in relation to women and 62% of enquiries relate to people over 65.

The report highlights six case studies, in which one of an 89-year-old man resulted in a police investigation into wilful neglect.

The report does not identify the care homes, but is using the investigations as learnings tighten up procedures and communication between agencies coming into contact with vulnerable adults.

One of those cases is that of Ben, 89, a butcher by trade who would reminisce about this with staff.

His daughter wrote to the nursing home to say Ben was left to fester in his own urine after having pulled out his catheter, that he had not washed for days and was left unfed. She was told the home had staff shortages.

Ben was admitted to hospital and the hospital immediately raised a safeguarding concern under the category of Suspected Acts of Omission and Neglect by the Nursing Home. As Ben was noted to have 12 pressure ulcers and bruises over his body.

Police were called but a criminal prosecution against the provider did not take place, due to lack of evidence.

Following the enquiry, Ben’s daughter said: “It is important to me that lessons are learnt from my father’s case so this doesn’t happen to anyone else. Professionals should ensure that they take responsibility for referring and follow up the outcome of that referral, when pathways relevant to their role are not/or no longer appropriate.”

In another case cited by the report, Carol, recently widowed, fell and broke her shoulder.

Carol started drinking alcohol and stopped taking her medication for schizophrenia.

Carol was supported by a number of agencies over the next three months, including hospital stays, community mental health support and a package of care from a home care agency. Safeguarding concerns were raised by a number of agencies in regard to self-neglect but the local authority did not follow its own safeguarding plan.

So she fell through the gap and was sent home.

When the package of care was restarted a few days after discharge from hospital, Carol did not answer the door. The following day, after Carol didn’t answer the door again, the carer called the police where it was discovered that Carol had passed away.

The subsequent review found that there was a lack of a co-ordinated approach which would have given professionals a more informed insight into Carol’s situation.

The report also highlights strain on services due to the pandemic.

“There is no doubt that the combined impact of the pandemic and growing demand has put huge strain on services as well as the ability to deliver all of our ambitions as a partnership,” saidTeresa Bell, the independent chair.

“We have had to reprioritise and remain flexible, in order to respond to those issues which, require the most urgent attention.”

The report goes before West Berkshire’s Health and Wellbeing Board on Friday, February 18.


Source: Cases of neglect highlighted in annual report by the West of Berkshire Safeguarding Adults Partnership Board (

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