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A matter of life or death: a rapid review assessment of London’s safeguarding adults reviews to inform the future of mental health adult social care under a new Mental Health Act

Research output: Book/ReportCommissioned reportpeer-review

Original languageEnglish
Place of PublicationLondon
PublisherNIHR Applied Research Collaboration South London; NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London
Commissioning bodyLondon Association of Directors of Adult Social Services
Accepted/In press15 Jul 2021
Published8 Sep 2021


King's Authors


Safeguarding Adult Reviews (SARs) can be a valuable source of learning to improve mental health care. In light of the government’s commitment to reform the Mental Health Act 1983, this report summarises the qualitative learning from 77 SARs published across 24 London boroughs covering the period January 2017 to November 2020. The premise of this report is that the reform of the Mental Health Act will also prompt a ‘wake up’ of the entire mental health system in London and the rest of England in which parity of social care with health care becomes the ‘new normal’. The SARs analysed for this report tell the stories of Londoners who experienced mental health problems and came to harm or died as a consequence of their condition despite having been in contact with mental health care services and others. From the rapid analysis of the SARs case clusters emerged, with similarities in the individuals’ stories and outcomes. These clusters show that there might be groups of people who require particular attention when it comes to reforming the Mental Health Act – and with it the mental health social care ‘offer’. The stories of these individuals also raise some concerns around human rights, equality and inclusion with the question: Is enough being done to protect the rights of vulnerable people with mental health problems who receive mental health social care and who may rely on social care to respect these rights? The analysis further suggests that there are two major problem areas across virtually all the cases and clusters – professional knowledge and usage of the Mental Capacity Act 2005 and inter-agency working and communication.

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