Learning from tragedies: an analysis of alcohol-related Safeguarding Adult Reviews published in 2017

24 July 2019

Executive summary

In 2017, 5,507 deaths in England were directly attributable to alcohol, an increase of 11% since 2006, while hospital admissions caused primarily by alcohol were 17% higher over the same period. The total number of hospital admissions for which alcohol was a factor was close to one million, or about 7% of all hospital admissions. Serious cuts to alcohol treatment services are making things worse, with many people in desperate need of support falling through the gaps.
Vulnerable adults are particularly at risk. They can be deeply affected by alcohol, whether as a heavy drinker themselves or as someone who is negatively affected by another person’s drinking.

Research objectives

We wanted to better understand the role that alcohol plays in those situations where vulnerable adults die; and to draw out any lessons that could be learned. We analysed the 11 Safeguarding Adult Reviews (SARs) published in England in 2017 in which alcohol was identified as being a significant factor in the person’s life and/or death. A SAR is commissioned following the death or serious harm of an adult with care and support needs. While each SAR can contain useful learning in its own right, we also wanted to look across all alcohol-related SARs to see whether there might be broader patterns and broader learning.

Therefore we undertook an in-depth analysis of every review and analysed collective themes. The results are published within this report. We drew on previous work in this area – see Appendix 3. Before summarising the findings, it is essential to note that these SARs reveal tragic stories of human lives lost in sometimes terrible circumstances that no-one should have to go through. These people deserved better from the world around them. None of these people needed to die the way they did; the tragic nature of their deaths was preventable. We as a society owe it to the memories of these people and their families to make the most of the learning offered by these reviews and to intervene better. This is urgent, especially for those people who are alive today and are at risk of being the subject of a future SAR themselves.

Summary of findings

The overarching finding was that, perhaps unsurprisingly, most of the adults featured in these reviews had multiple complex needs in addition to alcohol misuse, including mental health problems, chronic physical health conditions, neurological conditions caused by alcohol, self-neglect, exploitation by others, unfit living conditions, and experiences of a past traumatic event such as bereavement and physical or sexual abuse. In almost all cases, support services failed to cope with that complexity. Two common stories merged. First, a significant number of reviews (six of 11) indicated that the vulnerable adults were being exploited and abused. Their vulnerability stemmed from a range of circumstances, from severe mental health problems to disability. The cause of death in three of these cases was murder or injury from physical abuse.

Second, four of the SARs involved men who had become unemployed, lived alone and lost contact with their families. The cause of death in these cases was related to self-neglect and refusal of care from services. Despite the Care Act (2014) identifying people with alcohol problems as possibly needing care and support, there is little guidance in applying this legislation, or the equally relevant Mental Capacity Act (2005), to this group of people.

This report identifies some common characteristics among the adults whose deaths resulted in the SARs and considers how their alcohol misuse was perceived by the practitioners who were working with them. It reveals the extent to which alcohol is a contributory factor in a number of tragic incidents and highlights some key themes that can inform improved future practice, such as better multiagency working, stronger risk assessments, and improved understanding and training for practitioners to help them better identify and support, in a non-stigmatising way, vulnerable people who are experiencing alcohol harm.

It also considers these cases in the context of the law and discusses how practitioners could better apply the relevant legislation to similar situations, as well as how the current guidance could better address the issue of alcohol-related self-neglect.