Safeguarding Adults Review Lessons from Hospital Discharge

The Lewisham Safeguarding Adults Board (LSAB) has published a new Safeguarding Adults Review (SAR) Thematic Acute Hospital Discharge Report, examining how adults with complex care and support needs are discharged from acute hospitals back into the community.

Published on 29 May 2026, the review was commissioned following a small number of serious cases involving Lewisham residents who were discharged home from hospital and subsequently died. The review does not investigate or determine causes of death. Instead, its purpose is to identify learning opportunities, improve practice and help prevent similar situations in the future.

Although the number of cases reviewed was small, the report describes them as "sentinel events" that reveal wider system risks which could potentially affect many other residents.

The review recognises the significant pressures facing health and social care services and notes that around 10,000 hospital discharges take place in Lewisham each year. It also highlights examples of good local practice and effective partnership working.

The findings are intended to support continued improvement across organisations involved in hospital discharge planning, adult social care and community support services.

Residents and professionals can read the full report and accompanying 7 Minute Briefing on our Safeguarding Adults Review Page.