Background
52-year-old man with a long history of paranoid schizophrenia and complex mental health needs. Loving brother, uncle, musician and practising Hindu. He lived successfully in supported accommodation for over 20 years in Haringey and moved to a secure lifetime tenancy in Ealing in October 2024. Anish was found deceased in June 2025 after a prolonged period out of contact with services.
What went well
- There was strong long-term support and relationships within supported accommodation.
- Practitioners made significant efforts to secure stable housing and support independence.
- Anish was provided with persistent practical support following the move.
- Practitioners recognised and escalated concerns regarding self-neglect and deteriorating wellbeing
Good practice identified
- Strong long-term support and relationships within supported accommodation.
- Persistent efforts by multiple agencies to maintain contact and monitor wellbeing
- Practitioners recognised and escalated concerns regarding self-neglect and deteriorating wellbeing
- Multiple agencies continued trying to establish contact with Anish as concerns increased
- Safeguarding referrals were made and crisis concerns were raised with mental health service
Key learning
- Assessments must consider the formal and informal support that enables independence.
- Moving from supported accommodation can create vulnerability if support arrangements are not maintained
- 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 discussion
- Partners must have clarity about who is coordinating risk and overseeing wellbeing
Key recommendations
- Strengthen transition planning for adults with complex needs.
- Improve continuity of support following housing moves.
- Enhance multi-agency responses to self-neglect.
- Embed recognition of cumulative risk and shared ownership of safeguarding concerns
Key message
- Understand what support makes independence possible
- Recognise cumulative risk, not isolated incidents
- Treat repeated inability to make contact as a safeguarding concern
- Bring agencies together early
- Establish clear ownership when risks span organisations
- Maintain visibility during transitions and staff absence
Summary
The SAR's main organisational learning is that agencies need to move from single-agency responses to a coordinated multi-agency model, with stronger transition planning, clearer ownership of risk, better continuity of support, and earlier recognition of cumulative self-neglect and disengagement.