Annual Reports

The Care Act 2014 requires each Safeguarding Adults Board (SAB) to publish an annual report.

The Care Act (Schedule 2.4 (1) a–g) defines the minimum content of an annual report.

As soon as is feasible after the end of each financial year, a SAB must publish a report on:

What it has done during that year to achieve its objective,
What it has done during that year to implement its strategy,
What each member has done during that year to implement the strategy,
The findings of the reviews arranged by it under section 44 (safeguarding adults reviews) which have concluded in that year (whether or not they began in that year),
The reviews arranged by it under that section which are ongoing at the end of that year (whether or not they began in that year),
What it has done during that year to implement the findings of reviews arranged by it under that section, and
Where it decides during that year not to implement a finding of a review arranged by it under that section, the reasons for its decision.
The performance of member agencies and how effectively, or otherwise, they are working together should be included in the report.

The annual report must be sent to:

The Chief Executive and leader of the local authority which established the SAB.
Any local Policing body that is required to sit on the SAB.
The local Health Watch organisation.
The Chair of the local Health and Wellbeing Board.

Annual reports should form the basis for the consultation on the strategic plan for the coming year.

A SAB should seek assurance from its members that the annual report has been considered within their internal governance processes.

LSAB Annual Report 2024-25

Message from the Independent Chair

“It is against this background of increasing understanding and demand for
safeguarding activity that this report demonstrates creativity, activity and
persistence to reduce the safeguarding risk to adults”.

I am delighted to present this Annual Report from the Lewisham Safeguarding Adults Board for 2024-2025. It represents the continuing hard work and dedication of so many professionals, volunteers and members of our community in their endeavours to ensure neighbourhoods are as safe as they can be, and that adults are protected as much as possible from all forms of abuse and exploitation.

We are, though, living at a time when we are still developing our understanding of adult safeguarding in terms of its scope, impact and effect. Hence, as this report shows, the number of safeguarding enquiries and the differing types of issues they cover is growing significantly every year, and this past year was no exception.

It is against this background of increasing understanding and demand for safeguarding activity that this report demonstrates creativity, activity and persistence to reduce the safeguarding risk to adults, and also to respond appropriately when some of the most vulnerable members of our community are victims of abuse and or exploitation.

The safeguarding board has a membership representing all the statutory welfare services, plus the voluntary sectors, ensuring the voices of the community are heard.

The significant achievements represented in this report are due to board members' commitment and dedication, and I therefore want to thank them all on behalf of the citizens in Lewisham.

The report is packed with insights and information which I trust will help you gain a good understanding of the activities of the board in the past year and its plans for the future.

The fact that we as a society need Safeguarding Adults Boards is a reflection of some of the problems and issues that we face in society, and the Safeguarding Adults Reviews (SARs) we have undertaken are a reminder that care services and support are not always of the standard or quality we would rightly expect.

The board is committed to doing all it possibly can to drive up standards and to ensure services are safe and appropriate.

Finally, I would like to thank the board staff members. They are a very small team, yet their commitment and dedication is clear for all to see in this report; we all owe them so much. It has been my privilege to have chaired this board over this past year, but this will be my final report as I need to find more time to care for my own family.

I will be leaving the board in a very healthy state and I look forward to hearing how its work develops in the future.

Professor Keith Brown

Summary of Delivery in 2024-25

The Board continued to oversee the delivery of its strategic aims and objectives.

Key areas of work included:

Safeguarding Adults Reviews (SARs)

The Board continues to be busy with several notifications being submitted throughout the year. Details of the two published SARs from
the reporting period and further information can be found on pages 13 & 14.

Learning and Development

The Board delivered another record number of learning activities during the last 12 months reaching increasing numbers of participants. The collated evaluation feedback from these events produced an overall score of 9:10 from the delegates who were asked to rate how their knowledge, skills and confidence had improved as a result of their attendance.

Audit and Scrutiny

The Safeguarding Adults Partnership Audit (SAPAT) is our annual quality assurance process. A Heatmap is outlined for the key public sector agencies. There is a continuous focus on audit and scrutiny which is delivered through the work of the Board’s Sub-Groups and other forums.

Community Engagement

A number of events were delivered to engage members of the public and those who have lived experience of abuse. This included involvement with the Board’s development session. Their feedback is used to help ensure strategic priorities are relevant and improve the focus on prevention. 3,000 information leaflets were also circulated across Lewisham.

Self-Neglect High Risk Panel

Important work continued throughout the year to develop new policy and procedures.

Safeguarding Adults Partnership Audit (SAPAT)

The Board conducts an annual audit to ensure partners understand what is working well and what challenges exist within their own organisations and at a partnership level. It also provides an opportunity to identify strategic priorities for the next year.

Metropolitan Police Service
Achievements:

Focused training on domestic abuse to enhance investigations.
Despite financial challenges there has been investment in public protection teams.
Specialist mental health team, which also advises and supports other staff.
Training on self-neglect and professional curiosity (learning from SARs).
Work on race action plan and leadership culture to improve community cohesion.

Challenges and Future Developments:

Ensuring there is consistency and legal compliance in relation to safeguarding.
Poor data recording and sharing in relation to safeguarding via CONNECT system.
Need for more collaboration on inter-agency training.

“We aspire to be the most trusted police service in the world”.

NHS South East London (SEL) Integrated Care System (ICS)

(Achievements:

Reducing the number of care home acquired pressure ulcers - enhanced training.
Community Pressure Ulcer Panel’s preventative work in improving quality of care.
Recruitment of an Independent Gender Violence Advocate into primary care.
Reviewing accommodation for homeless asylum seekers - safeguarding focus.

Challenges and Future Developments

Workforce pressures in primary care can inhibit attendance at learning events.
Creating more co-ordination between children’s and adult services.
Expanding perpetrator programmes for domestic abuse.

“Adopting a Think Family approach that involves an open door into
a system of joined up support”.

Lewisham and Greenwich NHS Trust (LGT)

Achievements:

Review of the Trust wide mental capacity assessment form.
Routine inquiry into domestic abuse now embedded into ED triage at *UHL.
Prioritising safeguarding at all major trust events and patient safety incidents.
Planning for a dedicated safeguarding conference.

Challenges and Future Developments:

Over reliance on e-learning which limits effectiveness of personal development.
Professional curiosity can only improve if unprecedented workload is addressed.
Shortage of mental health beds translates into pressure on acute services.

“We talk about self-neglect at training, and acknowledge the reality and
difficulty of implementing best practice”.

Lewisham Council - Adult Social Care (ASC)

Achievements:

Rollout of updated self-neglect policy ensuring practitioners have clear guidance.
Review of the internal safeguarding systems to improve responsiveness.
Mental Capacity Act assurance: audits, training, and incident reviews.
Learning & development culture: staff forums, briefings, performance monitoring.

Challenges and Future Developments:

Continue to improve the local safeguarding case management database.
Significant increase in safeguarding activity and flow of intelligence into ASC.
Changes to the ASC structure to help manage the safeguarding workflow.

South London and Maudsley NHS Foundation Trust (SLaM)

Achievements:

Improving the status of safeguarding on the corporate risk register.
Implementation of the trust wide sexual safety policy and linked training.
Introduction of quarterly safeguarding supervision sessions.
Improved focus and oversight of Mental Capacity Act assessments.
Appointment of a Think Family lead and steering group.
Partnership working with black led organisations to develop anti-racist practice.
Significant increase in safeguarding training and achieving related targets.

Challenges and Future Developments:

Continue to improve the focus on domestic abuse.
Further strengthen the use of advocacy services.
Staffing problems leads to teams being over stretched and exhausted.

“Improved safeguarding knowledge across the trust is evidenced by the
number of referrals being raised and informed curiosity during supervision”.

LSAB Partnership Achievements: (Based on combined feedback from partners)

Ongoing commitment of partner agencies.
Communication and engagement continues to be an excellent standard.
Volume and quality of outcomes delivered by the Sub-Groups.
Delivery of Safeguarding Adults Reviews (SARs) and learning this generates.
The number and standard of resources created for professionals.

LSAB Partnership Challenges:

Addressing the complex problems linked to hoarding and self-neglect. Managing the increasing volume of Safeguarding Concerns. (3,376 in 2024-25).
Ensuring professionals maintain their focus on prevention.
Maintaining “the passion and compassion”.

Examples of Engagement with Partners

Homelessness and Safeguarding Workshop - 999 Club: 21 May 2024

The Board jointly hosted this Workshop at the 999 Club in Deptford. This was a significant and powerful event bringing 30+ people from 15 separate agencies together to build relationships and a shared understanding of the issues.

The signature presentation at the event was given by Tasia a service user and now peer support worker who talked about her experiences which are outlined on the following page.

The event coincided with a letter being published by the government announcing that every Safeguarding Adults Board must consider how the homelessness sector is represented within this statutory partnership.

“SABs should ensure their governance structure has the necessary mechanisms to hold partners working with people rough sleeping accountable”.

This has been agreed and a specific action plan was developed based on the discussions at this event which will be repeated in October 2025.

Missing Adults Workshop - Metropolitan Police: 25 July 2024
The aim of this event was to bring professionals from a range of sectors and backgrounds together to discuss how we can create a best practice safeguarding response for missing adults, and in doing so, help prevent future incidents and improve the aftercare that is offered to this group of people.

Overview of good practice:

Identify trends, hotspots, emerging issues, and build the local picture.
Set up a local multi-agency strategic group to oversee the approach and protocols.
Conduct safe & well or prevention interviews and practices.
Conduct return interviews.
Ensure necessary staff have appropriate training.
Make practical changes to locations (built environment).
Ensure everyone knows how and when to report someone as missing.

Carers Rights Day - Imago: 21 November 2024

19,957 informal and unpaid carers were identified in the census in 2021 in Lewisham, but Carers U.K. estimates this it is likely to be double that number in each area.

Only c.2,000 of these individuals (5-10%) are currently registered with Imago the commissioned carers support service in the borough, so Carers Rights Day is important in helping to raise awareness across local communities and ensure support is being offered to those who may need it. The Board supported the activities held by Imago and delivered two safeguarding workshops at the Glass Mill Leisure Centre.

What People with Lived Experience Said

Homelessness

Tasia shared her personal story with Board member in July 2024 and spoke highly of the event at the 999 Club in May that year. She talked about her life experiences and her initial contact with services, expressing that she would have sought help earlier if she had known about the 999 Club sooner. Tasia emphasised the need for strict no-drugs policies within accommodation settings and highlighted the need for staff to always be empathetic and supportive to those that are homeless as this really makes a big difference.

“Empathy costs nothing”.

Tasia also discussed issues related to unsafe housing, noting that disrepairs and anti-social behaviour are not always acted upon appropriately, and that Safeguarding Concerns that had been submitted regarding her circumstances had also been
disregarded. Tasia reinforced the need to receive acknowledgement from the local authority to outline why this was the case and what other avenues of support were available to her.

“Just putting a roof over someone’s head is not enough”.

Learning Disability
Aisha and Tom who are peer advocates from Lewisham Speaking Up (LSU) attended the Board meeting in July 2024 to talk about housing and home environment, which is often impacted due the current crisis which can have an impact on mental health.

“Adults living with a learning disability have high aspirations too. ”

The single biggest issue (50% of the total) that the advocates within LSU come across is housing, but councils and housing associations do not communicate very well with LSU about this, which is frustrating. This can often cross-over with and connect to Safeguarding Concerns linked to anti-social behaviour, or self-neglect, disrepair, and hoarding.

“Agencies do not take LSU seriously, or listen to us, and we are left out of the loop” .

Transitional Safeguarding - Care Leaver
Jade shared her experiences with the Board in January 2025 as a care leaver who moved frequently and relocated from London to Birmingham and then to Blackpool after growing up in Lewisham. Jade faced various risks and outlined that there was no clear plan and therapy was not provided which led to her frequently running away often due to not feeling safe. Jade emphasised that she should have received better support and that there were no discussions about potential risks when she eventually moved back to London.

“Corporate parents should treat care leavers the same way they would treat their own children”.

Learning, Training and Development

Key Highlights
The Foundation Level Introduction to Safeguarding Training continues to be delivered every 6-8 weeks which is open to anyone to attend, including carers and members of the public. This was accessed by 164 people throughout the year.

A more detailed course is also offered for Leaders and Managers which is delivered quarterly and was attended by 41 people during 2024-25.

A new Professional Curiosity training course was trialled initially after extensive research and then launched during the year, and will be delivered every 3 months. The 2nd National SAR Analysis identified practice shortcomings in 44% of SARs and only 3% identified good practice. See page 16 for more detail.

We held a joint learning event for SARs Maria and Maureen in March 2025 which was attended by 199 delegates, providing an important opportunity to share and discuss the key aspects of these two high profile cases.

In addition the LSAB Business Unit played a leading role in the planning of the London SAB Conference which was held to coincide with the National Adult Safeguarding Awareness Week 18-22 November 2024. 675 delegates attended this event and Lewisham had the second highest level of attendance of any of the London boroughs with 98 people participating.

All of the development activities provided by the Board are free of charge.

Communication and Engagement Activities

LSAB Communication & Engagement (CE) Strategy 2024-25
This was updated in July 2024 but the overriding principles remain the same:

Below are some examples of the CE work delivered in the last 12 months:

3rd Annual Housing Summit December 2024
Hosted in person this year to provide an opportunity for providers to meet, network and discuss some of the key issues in relation to their work linked to safeguarding.

Community Drop in - Catford Library
Providing an opportunity to listen to people’s experiences, hand out leaflets, and answer any questions members of the public may have throughout the year.

Networking and Learning Events
Bespoke sessions were delivered for Age UK, Community Connections; Lewisham Speaking Up Advocates and Trustees; as well as generic sessions in the community.

Learning Culture Survey Autumn 2024

There is regular communication with frontline practitioners to collect their feedback and use this to inform the local approach,
policies and resources.

e-Bulletins
Circulated to an increasingly large number of individual email addresses (c.1,000) every 6-8 weeks with important updates regarding legislation, research and policy.

7 Minute Briefings
These briefings are published on varied topics throughout the year making it easier for professionals to read and digest important information in a bitesize format:

Maria SAR Published 11 December 2024

Maria was aged 54, a White British female, heterosexual, who had a home provided by a local housing association which was a temporary solution to her homeless situation. Maria was also supported by the tenancy sustainment team from a local homeless charity commissioned to offer such support. Maria was known to sleep on the streets and could often be found bedded down in the town centre. The reason for this is recorded as problems with neighbours.

Maria had a long history of treatment with substance misuse services for alcohol dependency. Maria had successfully completed alcohol treatment two months before the scoping period for this review and moved to the commissioned substance misuse service for continued support for alcohol use within the community. Following the loss of a family member at the end of the year before she died, Maria’s own health deteriorated, and professionals found it increasingly hard to engage with her. Following admission to hospital with a head injury, her family raised concerns regarding domestic abuse by her partner. Maria’s physical health then deteriorated, and she died on 2 June 2023, seven days after admission. The inquest is not concluded and therefore an official cause of death is not yet known.

Maureen SAR Published 10 February 2025

Maureen was a 66-year-old woman from a Black Caribbean ethnic background. She lived alone in a social tenancy provided by the local authority since 2011. Maureen’s friend since childhood and her goddaughter explained that Maureen had been a very intelligent, resourceful woman, who was excellent with money and had cared for her parents, her brother and other family members. Her friends felt Maureen had always experienced some challenges with her mental health and were aware that she had become increasingly withdrawn, isolating herself from others over the past decade.

Maureen had experienced a number of losses of her friends and family in a short period of time, perhaps due to these losses Maureen took to feeding local pigeons and would also bring them into her home. This affected the cleanliness and condition of her property and impacted on people living in the same block of flats. When asked by professionals about feeding and keeping birds, she either denied the behaviour or appeared to have no insight into the condition of her living environment.

There was a history of agencies failing to engage Maureen; she declined offers of care and support, and only appeared to participate in assessments when ordered or requested by the Court, although there was considerable multi-agency activity during the last year of her life. Having been reported as a missing person the police attended the property and found Maureen deceased in her home; she appeared to have been dead for some time.

All of the published SARs in Lewisham can be read here:
Lewisham Safeguarding Adults Board - Safeguarding Adults Reviews

Example: What Have we Learned from Safeguarding Adults Reviews (SARs)

We analysed all of the Lewisham SARs and linked intelligence since 2019 with the two following aspects of the Mental Capacity Act 2005 Code of Practice in mind:

Strategic Business Plan 2024-25

In line with the five priority areas there are a total of 23 actions that are planned for 2025-26 which is the most ambitious work programme the Board has ever had. This will include: a continuation of the comprehensive training programme including a new course to improve the focus on SCAMS and financial abuse; a review of the internal audit processes used by partner agencies in relation to mental capacity; a continuing focus on Think Family and homelessness; and new tri-borough guidance to be published on Missing Adults to help improve the local response to this subject in an area with one of the highest rates of missing people in London.

Full details can be read here:

Lewisham Safeguarding Adults Board - Partnership Compact and Strategic Business Plan 2024-2025

Download a copy of the LSAB Annual Report 2024-2025

Download a copy of the LSAB Annual Report 2023-2024

Download a copy of the LSAB Annual Report 2022-2023

Download a copy of the LSAB Annual Report 2021-2022

Download a copy of the LSAB Annual Report 2020-2021

Download a copy of the LSAB Annual Report 2019-2020

Download a copy of the LSAB Annual Report 2018-2019