Safeguarding Review Finds Failures After Man Found Dead
No review triggered despite multiple unsuccessful contact attempts
Reviews are triggered when there are concerns about the care received by a vulnerable adult. Picture: Ealing Council
November 11, 2026
Support agencies in the borough of Ealing have been urged to work together to prevent future deaths after a vulnerable man was found dead at his home in June 2025 after multiple unsuccessful contact attempts from services.
In October 2024, Anish, a 52-year-old “loving brother, uncle, musician and practicing Hindu” was moved from his supported accommodation of over 20 years in Harringay to a secure lifetime tenancy in Ealing. Just eight months later, Anish passed away after a “prolonged period out of contact with services.”
His case is one of two Safeguarding Adults Review (SAR) to take place in the borough in the last 12 months. A SAR takes place when an adult with care or support needs has been seriously harmed or died, and “there are concerns that agencies or services could have worked together more effectively to help keep the person safe.”
Anish is described in council documents as having a “long history of paranoid schizophrenia and complex mental health needs.” After being moved to Ealing, multiple different agencies attempted to contact Anish unsuccessfully.
Despite maintaining strong relationships with Anish in his supported accommodation, a multi-agency review and safeguarding decision never took place after failing to get in contact with the uncle following his move.
Reflecting on the “key learning” from the case in a council report, the Ealing Safeguarding Adults Board said that “moving from supported accommodation can create vulnerability if support arrangements are not maintained.”
The report later states: “Weight loss, missed medication, self-neglect, social isolation and disengagement should be viewed collectively as escalating risk… Repeated unsuccessful contact attempts should trigger multi-agency review and safeguarding decisions.”
Following the SAR, the key recommendations were to strengthen transition planning for adults with complex needs, improve continuity of support following housing moves, enhance multi-agency responses to self-neglect, and embed recognition of cumulative risk and shared ownership of safeguarding concerns.
In the second case, Reza is described as a father living at home with his wife and adult children. The report does not state whether Reza passed away – SARs can take place due to serious harm or death.
It says he “experienced advanced dementia, recurrent falls, frailty, weight loss, pressure damage, catheter related needs, reduced mobility and increasing dependency.” Reza’s growing care needs were largely met by his wife and son.
Professionals working with Reza responded to his individual needs, but there were “missed opportunities to reconcile the overall decline in his health” and to coordinate support as the risks increased.
His family “worked hard to care for him”, however this may have “hidden how difficult and demanding his care had become”. The report identifies good practice in supporting Reza to stay at home in line with his and his family’s wishes.
However, the board says that services “should regularly review whether family care arrangements remain safe and sustainable as needs increase. Despite repeated hospital visits, the admissions were not used as an opportunity to review his overall care. Instead, it simply treated the immediate health problem.
Reza’s situation did not arise from one single incident. Over time “his health declined, his care needs increased, and the pressure on family members grew.”
Although services responded to many of the individual issues he experienced, there were opportunities for agencies to work together sooner, recognise the overall level of risk, and provide more coordinated support, according to the report.
The board received a number of recommendations including: triggering earlier joint reviews between agencies, assessing carer strain and barriers to care, improvements to coordination on dementia, and strengthening decision making and practitioner confidence in capacity assessments.
Philip James Lynch - Local Democracy Reporter
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