SAR "Queenie" Published

The Bath & North East Somerset Community Safety and Safeguarding Partnership (BCSSP) commissioned a Safeguarding Adults Review following the death of “Queenie” in September 2024. Queenie was found living in conditions of severe self-neglect, with significant unmet health and care needs despite long-standing involvement from multiple agencies.

The review identified opportunities for agencies to work more effectively together in responding to self-neglect, understanding complex caring relationships, involving family members and advocacy services, and applying safeguarding processes consistently. It also highlighted the importance of professional curiosity, trauma-informed practice, and considering the wider circumstances and identities that can influence a person’s engagement with support.

The review makes five recommendations focused on strengthening multi-agency learning, improving understanding of safeguarding responsibilities and processes, embedding the refreshed self-neglect and MARM arrangements, adopting an intersectional and relationship-based approach, and increasing collaboration with advocacy and voluntary sector partners.

BCSSP and partner agencies are committed to implementing the learning from this review to improve safeguarding practice, strengthen partnership working, and achieve better outcomes for adults at risk across Bath and North East Somerset.

The full report and learning briefing can be accessed here.