#JusticeForCardon REVIEW: Full letter stating why Review rejected

19th December 2016

Dear Mr Sugg,

Re: Mr Cardon Banfield

I am writing to you regarding the referral for a Safeguarding Adults Review
(SAR) regarding the circumstances of Mr Banfield’s death. This referral was
made by Worcestershire County Council’s Adult Safeguarding Team following
your contact with them.

A SAR is a multi-agency review process which seeks to determine what relevant
agencies and individuals involved could have done differently that could have
prevented harm or a death from taking place. The purpose of a SAR is not to
apportion blame. It is to promote effective learning and improvement to prevent
future deaths or serious harm occurring again.

On receipt of the referral, information on the care and support provided to Mr
Banfield was requested from the Worcestershire Safeguarding Adults Board
(WSAB) partners and other agencies thought to be involved. Having considered
this information, WSAB made the decision not to carry out a SAR as, firstly, Mr
Banfield was deemed to, at his own choice, only have had very limited
involvement with services in Worcestershire. Secondly it became very clear
from the information gathered that he had actually spent very little time in
Worcestershire prior to his death. It would therefore not be appropriate to
commission a SAR as we do not believe there to have been a lost multi-agency
opportunity to work with the gentleman.

I appreciate that this is not the outcome that you had hoped for. However, I
should like to thank you for bringing this matter to our attention. It is important
that the Board are made aware of cases that may potentially require a SAR or
issues to be aware of. We will therefore be looking specifically at how the
safeguarding needs of the homeless and transient population are addressed as
part of our engagement strategy.

Yours sincerely

Kathy McAteer
Chair of the Worcestershire Safeguarding Adults Board


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