A Serious Case Review was commissioned by the Somerset Safeguarding Adults Board (SSAB) following the death of Dave  who took his own life in 2014, aged 43. Dave had sustained a traumatic brain injury in a road traffic accident in his early twenties, which left him with physical, cognitive and psychological issues. In addition, Dave had a dependency on drugs and alcohol.

The independent report published by the board today concludes that despite numerous contacts with many health and care professionals and the concerns of family members he was not provided with appropriate support.

It highlights a lack of joined up working across social care, health bodies and drug and alcohol services. No organisation took a lead role in determining a coordinated, multi-agency response and opportunities to intervene in an integrated way were missed.

The report highlights the invaluable role provided by provided by local brain injury charity, Headway Somerset, which supported Dave for more than 13 years.

The report makes recommendations about how services can best support people with multiple and complex needs, including that Dave’s case features in multi-agency training and be disseminated beyond Somerset to stimulate debate and improve multi-agency responses.

The report also calls for assistance from Headway – the brain injury association, to which Headway Somerset is affiliated, in achieving these objectives.

In June last year the report’s author, Margaret Flynn, presented Tom’s case to more than 100 professionals at an SSAB-organised, multi-agency learning event. Headway Somerset, which had provided Dave with valuable support for more than ten years, also contributed to the training.

The SSAB is a statutory partnership including Somerset County Council, Avon & Somerset Constabulary and the Clinical Commissioning Group who work together to protect vulnerable adults from harm.

Its Independent Chairman, Richard Crompton, said: “I would like to speak on behalf of the Board to express my deepest sympathy to Dave’s family for their loss. Safeguarding adults is everyone’s business and an absolute priority for the Board and its partners, as it should be for everyone, and this review has highlighted a number of areas which require our continued focus and attention.

“The review into Dave’s death made a number of recommendations, which the SSAB has fully accepted and will continue to oversee and monitor. I would like to publicly thank Dave’s family for their valuable input and involvement in working with both Margaret Flynn and the Board in helping us to identify the lessons to be learnt that will serve to prevent similar circumstances from occurring in Somerset in the future”.