Latest news from the Partnership Board
The TDSAP Board members recently met to review the Board’s current priorities and our business plan. To assess the relevance of these priorities, we received a presentation from an operational social worker on a case involving a person with complex care needs, reviewed key agency statistical data, and scrutinised our own performance.
Over the past twelve months, as a Board, we have collectively completed and published important pieces of work, including updates to our website on key safeguarding areas, a new information-sharing and escalation protocol, an easy-read safeguarding guide, and the publication of several safeguarding adult reviews. There were numerous other pieces of work completed, but they would be too many to mention.
The decision was made to continue working towards delivering our current priorities (https://www.devonsafeguardingadultspartnership.org.uk/document/strategic-business-plan-2025-2027/), but all members agreed that, moving forward over the next twelve months, we should focus our efforts on delivering key pieces of work. There was recognition that these pieces of work, which will include the further development of the Multi-Agency Risk Management Framework (MARM) and a greater drive to align with other strategic boards in both Devon and Torbay, will deliver the maximum benefits for professionals and the public, particularly for those with care and support needs and their families.
We will continue to keep you all updated on the progress of these pieces of work through this newsletter and on our website.
Safeguarding Adults Reviews (SARs)
Following SAR Recommendations, the TDSAP has previously published three animation videos which are available by clicking the links below.
Tricky Friends (mate crime)
Hidden Harms (older adults and domestic abuse)
Personal story at the Board, from frontline Social Worker – when love becomes risk
At a recent TDSAP Board meeting, an experienced practitioner from Torbay and South Devon NHS Foundation Trust shared the anonymised safeguarding journey of Grace. The story highlighted the complexities that can arise when an adult’s expressed wishes, familial relationships and safeguarding risks sit in tension.
Grace experienced a period of serious ill health which led to hospital admission and safeguarding concerns. While the expected pathway was for early safeguarding discussions and supported discharge planning, Grace’s fluctuating health and limited engagement meant that key meetings were delayed until she was well enough to participate. Capacity assessments identified periods where Grace lacked capacity, requiring best interest decisions to be made.
Grace expressed a clear wish to return home to live with her husband. However, the home environment presented ongoing challenges. Grace was only able to return to a conservatory, with clutter, restricted space and environmental concerns limiting the ability to provide safe care. Attempts at joint meetings were often difficult, with hostility and resistance to professional involvement impacting progress and making it challenging to establish Grace’s true voice.
A strengths based, multi-agency approach was adopted to balance Grace’s wishes with identified risks. A time-limited safety plan was agreed, recognising the risks while enabling Grace to return home with increased care, equipment where possible, and ongoing professional oversight. Advocacy support was used to maintain Grace’s voice when direct engagement became difficult, and capacity assessments were regularly reviewed.
Board members reflected on the level of persistence required where coercion, refusal to engage and threats towards professionals were present. Grace’s story demonstrated the importance of strong multi-agency working, proportionality and maintaining a focus on human rights. The case was shared as an example of applying Safeguarding Adult Enquiry learning in real time, supporting prevention rather than hindsight.
The Casey Review
Baroness Louise Casey published her review and initial findings on adult social care in March 2026, alongside a formal letter to the Secretary of State for Health and Social Care calling for immediate action on adult safeguarding. Drawing on evidence of repeated safeguarding failures and systemic weaknesses, the review concludes that current arrangements do not provide sufficient national oversight, accountability, or learning. Baroness Casey highlights recurring themes emerging from Safeguarding Adult Reviews across England and the limitations of the existing safeguarding framework.
Main implications for Safeguarding Adults Boards (SABs)
The findings have significant implications for SABs, particularly in relation to governance, accountability, learning from Safeguarding Adult Reviews, and the adequacy of statutory powers. The key implications for SABs are set out below:
· Lack of national leadership and oversight Baroness Casey concludes that adult safeguarding lacks effective national oversight, leaving SABs to manage serious and systemic risks locally without a mechanism to escalate concerns or ensure national accountability. This results in repeated safeguarding failures being treated as isolated local issues rather than system wide risks.
· Safeguarding Adult Reviews (SARs) are not driving system change SABs continue to identify similar themes through SARs, but there is no national system to collate learning, identify patterns, or translate findings into consistent preventive action. This limits the impact of SAB assurance and learning functions.
· Current safeguarding powers are insufficient in high risk cases The review highlights that existing statutory duties and powers under the Care Act do not always provide SAB partners with the clarity or leverage needed to intervene effectively in complex, high risk situations, prompting a call for urgent review of the adult safeguarding legal framework.
Further information can be found at www.caseycommission.co.uk
Multi-Agency Risk Management (MARM) Framework
The MARM Framework has been ‘live’ across Devon and Torbay for a few weeks now and initial feedback has been very positive with a growing number of MARM meetings already in place to support professionals working with adults who are experiencing high-risk complex situations.
The MARM framework guidance and principles have been shared previously across the system and are available on the TDSAP website by clicking this link:
The partner version of the MARM Framework (including partner contact details for the purposes of the MARM) was updated and recirculated on 23rd April via the TDSAP Board members and Operational Delivery Group Members. Please refer any queries to your organisation’s MARM Champion in the first instance.
To further support practitioners, the TDSAP has developed a set of Frequently Asked Questions (FAQs), please click this link to take a look:
MARM framework: Frequently asked questions
In addition, the following video resource provides a helpful overview of the MARM framework and how it operates in practice:
Video – Multi agency risk management (MARM) framework
The MARM Framework aims to promote early intervention, improve joint working between agencies, share risk and decision-making and focus on preventing harm before a crisis occurs.
To enable TDSAP to understand the types of MARM meetings being held and the key themes of abuse being addressed, practitioners are asked to continue notifying TDSAP of each MARM meeting.
This should be done by emailing a completed Appendix 3 Notification Form to:
safeguardingadultsboardsecure-mailbox@devon.gov.uk
The Appendix 3 Notification Form can be found within the guidance by clicking here: MARM Notification Form