Partnership working in action: MARM making a difference
Board members heard a powerful presentation from a frontline housing practitioner demonstrating how the Multi-Agency Risk Management (MARM) Framework helped support an adult experiencing multiple and complex escalating risks. It highlighted the strength of bringing together a range of agencies to share in risk assessment and actions to reduce those risks and achieve improved outcomes for an adult at risk. While a previous multidisciplinary meeting had already identified risks and immediate actions, the MARM framework enabled a strong collaborative response and agreed actions to the escalating risks with the adult present at the meeting and able to voice his views, wishes and safety concerns. As a result, partner agencies were able to respond effectively and jointly and thereby achieved better outcomes for the adult.
Members also discussed the importance of ensuring all organisations, regardless of sector, have confidence to utilise the MARM framework when required and that the framework supports the shared responsibility of a collaborative approach to high risk situations at the earliest opportunity.
MARM leaflets have now been published on the TDSAP website to support your practice and are available here.
FOR YOUR PRACTICE Where an adult is experiencing complex, persistent, or escalating risks, consider whether the MARM framework could support a collaborative, preventative and early intervention-focused response to reduce risk and improve outcomes for the adult’s health and wellbeing.
Embedding learning from Safeguarding Adults Reviews
The Partnership is moving from a period focused on responding to a significant number of recommendations from Safeguarding Adults Reviews towards embedding the learning and assuring itself that improvements are being sustained in practice across partner agencies.
Board members highlighted the importance of robust internal governance arrangements, ensuring organisational responses fully reflect agreed SAR recommendations before final sign-off.
FOR YOUR PRACTICE How does SAR learning influence your day-to-day work? Learning from reviews only improves outcomes when it results in lasting and meaningful changes to practice, supervision, and decision making.
Publication of SAR Joe
SAR Joe was published on the TDSAP website in September. Joe was a 43-year-old White British man from Devon who had lived for many years with severe and enduring mental health issues, substance misuse issues, and experiences of homelessness and rough sleeping. In the months before his death, his mental health deteriorated significantly, with increasing psychotic symptoms, self-neglect, and complex support needs.
Following a hospital admission under the Mental Health Act (1983) in July 2023, Joe was discharged from inpatient care in October 2023 without secured accommodation and was effectively homeless. He died five days later.
The Safeguarding Adults Review (SAR) was commissioned to identify learning around the support provided to an adult with multiple disadvantages, including mental health issues, substance misuse, homelessness, and self-neglect. The review explored how partner agencies worked together to assess risk, coordinate care, and plan for discharge and ongoing support.
Annual report published
The TDSAP Annual Report, Executive Summary and updated Business Plan have now been published. The Annual Report highlights the collective safeguarding work undertaken across Torbay and Devon during the previous year and demonstrates the value of a strong partnership approach to working collaboratively to protect adults at risk.
Board members discussed continued increases in safeguarding demand and the importance of
understanding better the rising demand. Early analysis suggests that many contacts received by safeguarding adult services do not ultimately progress to safeguarding enquiries, for a number of reasons, but often as concerns relate to welfare matters and not concerns regarding ‘abuse and neglect’, creating opportunities to improve understanding of safeguarding adult criteria, and for the consideration of alternative referral pathways as appropriate.
KEY MESSAGE Good safeguarding relies on everyone understanding when a concern should be raised and ensuring people access the right service at the right time.
Devon & Cornwall Police: Strengthening responses to vulnerability
Progress continues following the recent Devon & Cornwall Police effectiveness, efficiency, and legitimacy (PEEL) inspection. An update from Devon and Cornwall Police emphasised that work continue to improve:
- Responses to vulnerable adults.
- Identification of repeat victims.
- Recognition of cumulative and escalating risk.
- Information sharing and multi-agency collaboration.
- Safeguarding responses linked to domestic abuse and serious harm.
Board members highlighted the importance of ensuring learning from inspections, MARAC reviews, Safeguarding Adults Reviews, and partner audits is connected wherever possible.
Members also noted increasing demand in domestic abuse concerns and the need for clear escalation routes when agencies have urgent safeguarding concerns.
FOR YOUR PRACTICE Consider the wider history when assessing risk. Individual incidents rarely tell the whole story. Patterns of repeated harm often become visible only when information from multiple agencies is brought together in a shared risk assessment.
Understanding safeguarding demand and safeguarding adult criteria
The Board reviewed Devon County Council’s Integrated Adult Social Care safeguarding performance and improvement activity. Discussion focused on:
- Growing demand for safeguarding adult services
- Variations in safeguarding activity across local areas
- Consistency of decision-making and safeguarding criteria
- Earlier intervention opportunities
- Learning from concern referrals that do not meet safeguarding adult criteria.
Examples discussed included referrals where adults were awaiting care and support assessments, support or where concerns related to welfare matters and had already been resolved. Board members agreed that further work across Torbay and Devon could help strengthen consistency and shared understanding of safeguarding criteria and alternative routes for welfare related matters that do not necessarily require a safeguarding adult response
FOR YOUR PRACTICE Before making a safeguarding referral, consider whether the concern relates to ‘abuse and neglect’ or whether another referral pathway for welfare, or care and support needs may provide a more appropriate and effective response. High-quality referrals support better outcomes and help all partner agencies to prioritise those at greatest risk.
Looking Ahead: PREVENT Learning and risk management
The Devon and Torbay PREVENT Partnership has begun considering emerging findings from the Southport Inquiry.
Early themes relate to:
- Risk management
- Threshold decision-making
- Missed opportunities for intervention
- Multi-agency information sharing.
The Board welcomed future discussions to consider how this learning may apply locally across both adult and children’s safeguarding partnerships.
FOR YOUR PRACTICE Professional curiosity remains one of the most effective safeguarding tools. Where concerns do not meet thresholds but continue to cause unease, explore what alternative support, monitoring, or information-sharing arrangements may help explore and manage risk.
Keeping safeguarding everyone’s business
This Board meeting reinforced several consistent safeguarding themes:
- Early recognition of risk
- Effective information sharing
- The value of multi-agency collaboration
- Learning from Safeguarding Adults Reviews
- Improving consistency in safeguarding decision-making
- Using data and quality assurance to improve services.
Above all, the meeting highlighted that effective safeguarding relies on organisations working together, remaining professionally curious, and maintaining focus on the adult’s lived experience.
TEAM CONVERSATION Discuss a recent situation where multi-agency working improved outcomes for an adult or a family. What made the partnership approach effective, and what learning can be applied to future circumstances?
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