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Lewisham Safeguarding Adults Board

Annual Reports

LSAB Annual Report 2022-23 front cover image

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 2022-2023

Keith Brown Image

Message from the Independent Chair

“One particular area of concern locally is the resourcing of mental health services, both for people with severe forms of mental distress requiring an inpatient bed, and for those living in the community, but in need of wrap-around mental health support”.

It is my pleasure to introduce this annual report which describes the work that has been done and the progress that has been made in keeping adults safe from abuse and neglect. We are slowly emerging from the worst of the Covid-19 pandemic but it continues to have an impact emotionally and practically for everyone. Services are having to readjust their ways of working, and for citizens the health, emotional and social impacts of the pandemic continue to be felt.

We are also experiencing a significant cost of living crisis, with a seemingly endless rise in the use of food banks and in poverty. We are only beginning to capture the data about the impact of this crisis on adult safeguarding, and I expect that next year’s annual report will reflect on what health, housing and social care services have witnessed. The Board has sought assurance from the local authority and its partners about the measures put in place to support citizens affected by the cost of living crisis.

We have continued to see the impact of financial austerity on public services. One particular area of concern locally is the resourcing of mental health services, both for people with severe forms of mental distress requiring an inpatient bed, and for those living in the community, but in need of wrap-around mental health support. We will continue to engage with mental health service providers and focus on improving the quality of practice.

The management of Safeguarding Adults Reviews continues to be a major focus of the Board’s work. It is reassuring that partner agencies are referring cases for consideration where an adult has died or experienced significant harm as a result of abuse and neglect. The Board has also kept a focus on how practice has improved and services developed, through webinars and assurance reporting, following the implementation of recommendations from completed reviews.

The Board has refreshed its Strategic Business Plan, a statutory requirement, to ensure that there is a clear focus on priority areas for assurance reporting and targeted task and finish work.

The Board has continued its work on developing its collation and reporting on performance data, and is actively supporting the local authority in its preparation for a forthcoming inspection by the Care Quality Commission. We have engaged directly with people with lived experience of adult safeguarding, but there is more that we must do in order to learn from those who have experienced abuse and neglect. This is one of my personal priorities.

I would like to thank Martin Crow and Vicki Williams who have supported me and taken forward much of the Board’s work. The Board’s web pages are a particular excellent example of the work they have put in. I also thank all of the Board’s partners for their contribution to adult safeguarding in Lewisham.

Professor Michael Preston-Shoot

Summary of Delivery in 2022-23

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 in this area of work which reflects the willingness of local professionals to seek transparency in relation to their practice. 

Learning and Development

The Board continues to invest heavily in this subject providing free to access courses in a range of subject areas. The Board supported the National Safeguarding Awareness Week in November 2022 by helping to provide a very extensive learning programme in London and nationally. 

Community Engagement

The Board routinely communicates and engages with around 200 local organisations in Lewisham, and continues to expand on this
outreach. A first of its kind Citizen’s Assembly was delivered by the Board in October 2022, which was co-produced and delivered by over a dozen local Voluntary and Community Sector Organisations. 

Seeking Assurance

An audit of safeguarding practice and delivery was completed by selected partners, and the trends used to develop the Board’s strategic priorities. The Housing Related Safeguarding Audit was finalised with a ‘Summit’ in December 2022 attended by a wide range of agencies. The Lewisham Adult Safeguarding Pathway was also reviewed in November 2022 based on feedback from local practitioners.

Lewisham Demographics

Partners Work

Metropolitan Police Service  

PC Chesca Rogers won a well-deserved national safeguarding award in 2022, as well as being recognised within the Metropolitan Police Service, for her outstanding work on the Domestic Abuse and Violence Disclosure Scheme (Clare’s Law).

Chesca has helped an incredible number of people in the last 2-3 years, as well as recommending changes to this national scheme to ensure this was more accessible during the Covid-19 pandemic period.

Clare’s Law is the most empowering thing I have ever worked on giving people the ability to safeguard themselves and their children. I would encourage anyone to use it as it is completely confidential and the person being enquired about will never know about this. You would check reviews about products before you buy online, so why not do the same about a potential partner”.

See here for more information on Clare's Law

Lewisham and Greenwich NHS Trust

The following case example helps to illustrate Clare’s Law in action:

A woman attended the Emergency Department (ED) at the University Hospital of Lewisham with injuries that suggested an assault. She reported that she was intoxicated but had no memory of an assault. The ED team made a safeguarding referral to the trust safeguarding team and she was admitted to a ward. The safeguarding advisor gained consent for a referral to the Independent Domestic Violence Advisor (IDVA) and suggested that the medical photography team record the injuries. 

A police report was discussed with the woman but she declined this. The IDVA then worked with the woman and discovered that she had just moved in with a new partner, and she had a history of experiencing domestic abuse in past relationships.

The IDVA supported the woman to make a Clare’s Law application to the Metropolitan Police, and the disclosure came back with some very concerning information about the history of the new partner. The woman decided to end the relationship and with the support of the IDVA she then made a report to the police, who requested the photographs. The IDVA offered a refuge referral, and the woman declined initially, but after further housing enquiries, this offer was remade and accepted. The IDVA also provided the woman with a voucher for food.

 “Thank you for everything. I felt really looked after”.

Lewisham Council - Adult Social Care

It has been 18 months since the Adult Multi-Agency Safeguarding Hub (MaSH) Team was established, which now addresses all of the Safeguarding Concerns that come into the local authority via Adult Social Care. During this time significant progress has been achieved and the team has been expanded, including the recent recruitment of a specialist domestic abuse Officer who will help to strengthen links with partners. 

Relationships with health colleagues have continued to improve and the time taken to effectively deal with pressure ulcer cases has significantly reduced. The link with adult mental health services has also been strengthened and there is now a dedicated mental health liaison social worker within the MaSH team, who will help to take forward the plan for further integration with South London and Maudsley NHS Foundation Trust (SLaM).

The amount of work that the MaSH Team has completed in the past year has also continued to grow, with around 500 referrals a month being managed, along with the 500 Police Merlin reports that are also triaged each month. Work is in progress to help make this system more efficient, and the MaSH Team will continue to develop their wider practice to help keep those most at risk of abuse and neglect in Lewisham safe from harm.

Learning, Training and Development

Amanda and Eileen Dean SAR Learning Event 22 February 2023

A record 1,248 people attended 35 learning and development events delivered by the Board during the last 12 months, which is significantly higher than any previous year.​ This was bolstered by over 400 people attending the online and joint learning event for the Amanda and Eileen Dean SARs which is the single largest activity ever held by the Board, that attracted attention from across London and the wider U.K.

This event was recorded and can be viewed here: Safeguarding Adults Reviews

We recommend you take the time to watch this video linked to these very high profile cases.

The success of the Board’s learning events are carefully analysed and are routinely scored as having a ‘significant impact’. 

Lewisham Adult Safeguarding Pathway

Another record 97,128 hits were achieved on the Board’s website (25% increase on the previous year), many of which were on the Lewisham Adult Safeguarding Pathway pages.

The Pathway was first published in April 2021 and has been constantly updated since then whenever the legal framework has changed, national guidance has been produced, or local policies created or updated. The ambition is to ensure every organisation (around 500 in Lewisham) and professional delivering services to, or working with adults at risk, are regularly accessing the Pathway.

 Please ensure you use the Lewisham Adult Safeguarding Pathway

Communication and Engagement

Citizen’s Assembly - Corbett Community Library: 7 October 2022

This Assembly, which was the first of its kind for the Board, was planned in a lot of detail, and delivered in conjunction with a wide range of Voluntary and Community Sector Agencies, and attended by 25 residents (plus carers) from Lewisham. 


 In total there were 250+ pieces of evidence and feedback was captured which has been collated, shared, and used to help shape the delivery of services locally. 

The most prevalent type of abuse disclosed by those attending was Domestic Abuse with people sharing their stories about the ways this was being experienced: 

Financial in nature, including the misuse or withholding of the adult’s benefits.

Familial abuse with younger adults abusing their parents or other family carers.

Female Genital Mutilation (FGM). This was highlighted as a significant issue with (east) African communities and unlikely to reach the attention of statutory services.

There may also be some inter-connectedness with ‘neglect’ by family members with caring responsibilities.

Safeguarding Information 2022-23


Table 2: Police MERLIN and Crime Report Investigation System (CRIS)

The MERLIN system is the way in which police share intelligence about adults where there are wider ‘vulnerability’ concerns, although this does not match the Care Act 2014 criteria in relation to ‘adults at risk’. Local police attended an average of 68 incidents per month in relation to adults with a “mental health crisis” (London average = 52), which in 8/9 of the months reported was in the top 10 in London.




The Domestic Abuse and Violence Against Women & Girls (VAWG) Strategy was published in December 2021. In the shorter term the aim was to continue improving awareness which would result in increased reporting, including within Adult Social Care, which should then reduce as interventions and prevention measures develop. 

Safeguarding Adults Reviews (SARs)

Amanda’. This review was published on 2 November 2022. 

 Amanda was a white woman who was born and grew up in southeast London. She died in May 2019 at age 57. At a young age, doctors had diagnosed Amanda with paranoid schizophrenia. Amanda developed a dependence on drugs and alcohol and used different substances at different times in her adult life.

The Care Home where Amanda lived provided her with 24-hour care and support. In 2018-2019 some of Amanda’s social life revolved around street drinking. When she was intoxicated Amanda was susceptible to falling and sustaining injuries. 

On 15 May 2019 Amanda did not return to The Care Home. Amanda did sometimes go missing for short periods of time. On this occasion, when she did not return quickly, family members began their own enquiries. The police responded by searching an unused garage in the borough. The garage was derelict and along with adjacent garages was due to be demolished as part of a redevelopment programme. It had been used as a rough sleeping site. To stop this activity, the entrance to the garage was boarded up in May 2019. On 5 July 2019 the police found Amanda’s body in the back of the garage. She had been missing for just under two months.

Read the 7 Minute Briefing for professionals to see the key learning points.  

Eileen Dean’. This review was published on 11 November 2022.

Eileen Dean was a 93-year-old white British woman who had moved into a care home in Lewisham in June 2020.  Although her capabilities were reduced by dementia, Eileen remained happy and contented.

"The Adult" is a white British man who was 62 years old when he physically assaulted Eileen. He had initially been admitted to a general medical ward at the University Hospital Lewisham (UHL) operated by Lewisham and Greenwich NHS Trust in July 2020 following alcohol withdrawal seizures.

 The Adult was detained under Section 2 of the Mental Health Act 1983 (MHA) on 3 Sept 2020, and eventually transferred to the inpatient psychiatric unit at UHL, and later discharged to the same care home as Eileen in December 2020.

The Adult was diagnosed with Wernicke-Korsakoff Syndrome, which has an established link in academic literature with aggressive behaviour. Between 5 August 2020 to 4 September 2020, there were at least 34 recorded incidents of The Adult’s violence or threats to patients or staff, including The Adult threatening to use a bread knife, scissors and dinner trays as weapons.

At 12.30am on 4 January 2021 Eileen Dean was assaulted whilst lying in bed by The Adult. Eileen sustained significant injuries and died in hospital later that day.

Read the 7 Minute Briefing for professionals to see the key learning points.

SAR Notifications between April 2018 and March 2023


During this period there were 21 SAR Notifications:

14 Female                       7 Male

The age range for the subjects of SAR Notifications is much lower than for Safeguarding Enquiries.

From these Notifications 9 SARs have been completed between April 2015 and 31 March 2023 and all have been published in the public domain. 

The dominant subject area that is prevalent in the Notifications is mental ill-health, which is a feature in 66% of the published SARs and 3 further ongoing reviews.  

In comparison mental ill-health was the Primary Support Reason in only 5% of the concluded s.42 Enquiries conducted in Lewisham in 2020-21 and 2022-23 (16% in  England).

 Adults from Black British, Black African and Black Caribbean backgrounds were  disproportionally more likely to be the subjects of a SAR Notification linked to mental ill-health.

Work of the Sub-Groups

Case Review Sub-Group                       

The Sub-Group oversees Safeguarding Adults Review (SAR) processes locally, and is led by the Board’s Independent Chair Professor Michael Preston-Shoot.

The group met 6 times during 2022-23 and considered or monitored 9 cases throughout the year, including 4 new SAR  Notifications.

A new joint protocol has been developed over the last year between the two safeguarding partnerships in the Borough, and the Safer Lewisham Partnership Board, which more clearly defines which statutory review process will take precedence when a case meets the criteria for more than one.

The board also contributed to the National SAR Library which holds all of the reviews which have been published in Lewisham since April 2015.

Lewisham Modern Slavery and Human Trafficking (MSHT) Network

The Board continues to administrate and support the delivery of this multi-agency group which meets on a quarterly basis.

Colleagues from the Human Trafficking Foundation also underpin this work, and in July 2022 they gave a presentation to the Board updating them on the local, regional and national picture. 

 In the last year the Borough has also been successful in joining other local authority areas in conducting National Referral Mechanism (NRM) decisions locally (rather than by the Home Office) for under 18’s. This is helping to speed up decision making dramatically and ensure victims of MSHT are receiving the care and support they require. 

Performance, Audit and Quality Sub-Group

This group continued to meet quarterly throughout the year to analyse and monitor the Board’s performance indicators and other relevant safeguarding information. This activity also plays a significant part in informing the ongoing development of the Board’s strategic objectives. The group provided the necessary governance for the LSAB Safeguarding Audit that was conducted during 2022-23. The findings from this were reviewed by partners at the Board’s Development Session in March 2023, which included a chance to constructively challenge each organisations individual self-assessment.

The Housing Related Safeguarding Audit has led to a further review of local Self-Neglect Policy and Procedures and the creation of a working group to take this forward. This group are considering the most suitable options for escalating risks in relation to this subject. This will lead to a follow-up and Second ‘Summit’ in December 2023. 

New! June 2024 - Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Toolkit from the LSAB

As promised in 2023, a review of the self-neglect and hoarding policy has been reviewed and published in June 2024.

Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Toolkit from the LSAB

Annex 2

Accompanying the Practice Guidance is the Self-Neglect High Risk Panel - Risk Assessment & Action Plan Template.

The group also commissioned a Hospital Discharge audit which will be reported on in next years’ Annual Report.

Liberty Protection Safeguards (LPS) Task and Finish Group

This group met periodically again throughout the year but has now been stood down as the Government have announced that

the Mental Capacity (Amendment) Act 2019 will not now be implemented in this current period of parliament, and as such the current Deprivation of Liberty Safeguard (DoLS) regime will prevail. There will be a review of DoLS procedures locally during 2023-24.  

Strategic Business Plan 2023-24


In line with the five priority areas there are a total of 22 Actions that are planned for 2023-24. This is the most ambitious work programme the Board has had since it became a statutory body in 2015.  

Full details can be read here:

LSAB Partnership Compact and Strategic Business Plan 2023-24


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


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