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It outlines her life, including underlying health conditions, welfare support history, and mental health service involvement, while clarifying that the review does not determine how, where, or when she died. The summary details changes to practice, key conclusions, and recommendations, supported by review methodology and legislative context.",{"@graph":63,"@context":112},[64,80,95],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/safeguarding-adults-review-patsy-executive-summary-march-2024/279362/",4,{"url":78,"name":59,"@type":81,"author":82,"headline":59,"publisher":85,"fileFormat":88,"inLanguage":57,"description":61,"dateModified":89,"datePublished":89,"encodingFormat":88,"isAccessibleForFree":90,"interactionStatistic":91},"DigitalDocument",{"name":83,"@type":84},"Oliver","Person",{"url":68,"name":86,"@type":87},"DocShare","Organization","application/pdf","2026-09-16",true,{"@type":92,"interactionType":93,"userInteractionCount":4},"InteractionCounter",{"@type":94},"ViewAction",{"@type":96,"mainEntity":97},"FAQPage",[98,104,108],{"name":99,"@type":100,"acceptedAnswer":101},"What is the purpose of this Safeguarding Adults Review for Patsy?","Question",{"text":102,"@type":103},"The review focuses on the circumstances of the care and support Patsy received before her death and how her death was not discovered for over three years, without re-investigating how Patsy died.","Answer",{"name":105,"@type":100,"acceptedAnswer":106},"Who commissions the Safeguarding Adults Review and when?",{"text":107,"@type":103},"In March 2023, the Surrey Safeguarding Adults Board commissioned the Safeguarding Adults Review to examine Patsy’s case and the delayed discovery of her death.",{"name":109,"@type":100,"acceptedAnswer":110},"Does the review decide how Patsy died?",{"text":111,"@type":103},"No. Determining how, where, and when Patsy died is the responsibility of the Coroner through an inquest.","https://schema.org",{"og:url":78,"og:type":114,"og:title":59,"og:site_name":86,"og:description":61},"article",{"robots":116,"canonical":78},"index,follow",{"doc_id":118,"site_id":56},279362,1789519351,{"code":4,"msg":5,"data":121},{"doc_id":118,"user_id":122,"nickname":83,"user_avatar":123,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":129,"language":130,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":131,"faqs":132,"seo_title":133,"seo_description":61,"update_tm":119,"read_time":134},8796095461610,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Safeguarding Adults Review  \n‘Patsy’Executive Summary  \nMarch 2024  \nAuthor Susan Harrison  \nAgreed by the SSABASE March 2024  \nTable of Contents  \n1 Patsy’s life, her death, and the delayed discovery of her death ...................................... 2  \n2 Changes to practice ....................................................................................................... 8  \n3 Conclusions ................................................................................................................. 12  \n4 Recommendations ....................................................................................................... 13  \nAppendices ......................................................................................................................... 15  \nAppendix 1 Safeguarding Adults Reviews [SARs] ........................................................... 15  \nAppendix 2 Methodology used in this SAR ..................................................................... 16  \nAppendix 3 Terms of Reference for the Review .............................................................. 18  \nAppendix 4 The Legislative Context and the Evidence Base for Patsy’s services ........... 20  \n1 Patsy’s Life, Her Death, and the Delayed Discovery of Her Death  \n1.1 This Safeguarding Adults Review [SAR] relates to a woman, Patsy, who was found dead in 2021. Subject to the findings of the Coroner’s Inquest , this is likely to have been some three or more years after she passed away.  \n1.2 Patsy is a name that the woman sometimes used as her preferred name.  \n1.3 Patsy was a single white woman in her late thirties. She lived alone in her flat as a tenant of Woking Borough Council.  \n1.4 The purpose of this SAR is not to re-investigate or to apportion blame, nor to establish how Patsy died. Determining how, where and when Patsy died is the responsibility of the Coroner through an Inquest. 1  \n1.5 In March 2023, the Surrey Safeguarding Adults Board decided to commission a Safeguarding Adults Review [SAR], to review:  \n• the circumstances of the care and support that Patsy had received in the years before her death, and  \n• how it came about that her death was not discovered for over three years.  \n1.6 Patsy’s family have experienced deep sorrow and distress at what unfolded in Patsy’s life and the circumstances of her death and how it was discovered.  \n1.7 This Safeguarding Adults Review is clear from the accounts that her family have given, that they were frequently and consistently rebuffed by Patsy, and that they accepted Patsy’s autonomy in deciding to live her life as she chose.  \n1.8 The review has not found anything that suggests that there were actions that family members could have taken that might have changed the course of events. Patsy was determined to exclude her family from her life, and her decisions to do so were respected by them.  \n1.9 Following her death, Patsy’s family have shown courage and determination to ensure that lessons are learned from what happened to her.  \n1.10 The SAR has found that there were many missed opportunities where, if services had intervened differently, Patsy’s inability to engage with others in relation to her distress and withdrawal might have been helped.  \n1.11 Patsy was born with a rare congenital condition known as Goldenhar Syndrome2 . Goldenhar Syndrome is an umbrella term for a range of changes that happen to an unborn baby’s face and body development in the first three months of pregnancy. The cause is believed to be an abnormality in a chromosome. It is not usually an inherited disorder. Each person with Goldenhar Syndrome is affected differently.  \n1.12 Patsy had profound hearing difficulties. Patsy’s body wasn’t symmetrical, and this affected the shape of her spine, one of her arms and one of her hands. Her face and  \n1 More information about the role of the Coroner and inquests can be found at  \n[https://coronerscourtssupportservice.org.uk/](https://coronerscourtssupp","cbCaimUtfuj0MogR","https://ap.wps.com/l/cbCaimUtfuj0MogR","pdf",390452,23,"English","# Patsy’s life, her death, and the delayed discovery of her death\n# Changes to practice\n# Conclusions\n# Recommendations\n# Appendices\n## Safeguarding Adults Reviews [SARs]\n## Methodology used in this SAR\n## Terms of Reference for the Review\n## The Legislative Context and the Evidence Base for Patsy’s services","[{\"question\":\"What is the purpose of this Safeguarding Adults Review for Patsy?\",\"answer\":\"The review focuses on the circumstances of the care and support Patsy received before her death and how her death was not discovered for over three years, without re-investigating how Patsy died.\"},{\"question\":\"Who commissions the Safeguarding Adults Review and when?\",\"answer\":\"In March 2023, the Surrey Safeguarding Adults Board commissioned the Safeguarding Adults Review to examine Patsy’s case and the delayed discovery of her death.\"},{\"question\":\"Does the review decide how Patsy died?\",\"answer\":\"No. Determining how, where, and when Patsy died is the responsibility of the Coroner through an inquest.\"}]","Safeguarding Adults Review ‘Patsy’ - Executive Summary - March 2024 | PDF",8]