A summary of learning has been published by the Safeguarding Board following a statutory serious case management review (SCMR).
It follows the death in 2019 of a man in his fifties, who had been deemed vulnerable due to poor physical and mental health over a number of years. For the purposes of the review, and to protect his identity, this individual has been referred to as ‘Mr H’.
The review was led by an independent off-Island expert – Domini Gunn – who was commissioned by the Safeguarding Board to produce the learning report. It is the first SCMR for a vulnerable adult to be carried out in the Isle of Man.
The review found that, except for the Isle of Man Prison and Probation Service, there was a lack of co-ordination across the agencies with which Mr H had contact.
The independent report sets out a number of learning points and recommendations. Broadly, these cover the areas of inter-agency working, information sharing, and both public and private housing provision in the Isle of Man. It also includes the improvements already made since Mr H’s death.
The Independent Chair of the Safeguarding Board, Glenys Johnston OBE, said:
'It can, understandably, be concerning when the need arises to commission a review of the safeguarding measures in place to protect a vulnerable adult. Perhaps all the more so in a close-knit community such as the Isle of Man where we know that most vulnerable adults are safe, supported and enabled to lead healthy and productive lives. Nevertheless, it is important that when practice can be improved, we embrace the opportunity and implement changes.
'One of the notable features of the review was the open and self-reflective contributions to the review and the total commitment to learn from it.
'The purpose of a SCMR is not to apportion blame, but instead to establish the facts, identify learning – both what worked well and what needs to be improved – and to support agencies to bring about change as a result. This is with the ultimate aim of raising standards and improving practice to properly safeguard and protect vulnerable individuals in the Isle of Man.
'This was a distressing case and it is the statutory role of the Safeguarding Board to support all of the agencies involved in implementing improvements so that similar situations can be avoided in the future.'
A copy of the learning report is available to download.
