A REVIEW has called for better support for vulnerable adults experiencing homelessness and multiple disadvantage after the death of a 68-year-old man.
The Safeguarding Adult Review (SAR), published on November 11 by the Somerset Safeguarding Adults Board (SSAB), investigated the death of a man in his 60s, referred to as 'Raymond,' who died in interim accommodation in December 2024.
Raymond faced a complex mix of challenges, including homelessness, trauma, bereavement, drug and alcohol dependency, cognitive impairment, frailty, financial exploitation and "unmet care and support needs".
The review examined how agencies responded to these overlapping experiences and highlighted how Raymounds death provides an insight into the "profound vulnerabilities experienced by older men living with multiple disadvantages".
"Raymond" was described in the review as a “gentle giant” and a father figure who had ties to Kent and had lived in Somerset for many years.
He had previously been married and was the father of six children but experienced traumatic bereavements that "left an indelible mark".
Despite this, the report states Raymound was widely known as a "cheeky chap" with a "warm and caring presence."
Many described him as a "gentle giant" who acted as an informal father figure within the community.
The report states he regularly sought and provided help to others, despite difficulties engaging due to memory loss, poor health, and intoxication.
Professor Michael Preston-Shoot, independent chair of the SSAB, said: "Safeguarding Adult Reviews are not about apportioning blame.
"They help us understand what happened, identify learning, and strengthen how organisations work together to protect adults at risk.
"Raymond was a valued member of his community whose warmth, humour, and resilience were recognised by those who knew him.
"This review also shows how fragmented responses, delay, and professional disagreement can leave an adult facing multiple disadvantage without the coordinated help they need."
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The review praised the dedication of frontline workers for "committed, compassionate and persistent frontline practice" but also identified key failings.
These included "significant gaps" in support for those facing financial exploitation alongside homelessness, delays in the system, unclear escalation routes, unresolved professional disagreements, and insufficient attention in trauma-informed practice to the relationship between homelessness, grief and bereavement.
The report also highlighted a lack of suitable accommodation for adults with care needs complicated by substance misuse, and the negative impact of stigma and uncertainty around mental capacity on safeguarding decisions.
Recommendations from the review include "refreshing" multi-agency guidance on financial abuse and exploitation, strengthening oversight of partner actions, and refining procedures for professional disagreements.
It also calls for better integration of bereavement support and expanded trauma-informed care.
Additional recommendations include creating a senior panel to resolve stalled complex cases, developing a business case for homecare in supported accommodation, and enhancing training around mental capacity, unconscious biases, and stigma.
Professor Preston-Shoot said: "The board will oversee a clear action plan so that the learning from Raymond’s life informs stronger safeguarding practice across Somerset.
"This includes listening to the person, acting promptly when risks escalate, valuing the expertise of all partners, and providing trauma-informed, legally literate, and coordinated support.
"We extend our condolences to Raymond’s family and loved ones, and thank everyone who contributed openly to the review."
Following the report, Adult Social Care has welcomed the findings of the Safeguarding Adult Review and says a number of improvements have been made since Raymond’s death.
These include closer integration between Housing and Adult Social Care, new specialist social worker roles supporting people sleeping rough, strengthened partnership working and the introduction of trauma-informed training and support.
Improvements have also been made to safeguarding practices, quality assurance, professional challenge procedures and Mental Capacity Act assessments.
Adult Social Care said further work is planned to strengthen support for adults experiencing homelessness, financial abuse and complex needs, while ensuring the lessons from Raymond’s case lead to lasting improvements in practice and outcomes.
The Somerset Safeguarding Adults Board includes Somerset Council, NHS bodies, police, probation services, and other organisations involved in protecting adults from abuse and neglect.
The full report and further information are available at www.ssab.safeguardingsomerset.org.uk.
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