Recommendations in a Learning from serious cases report published today (16 December 2025) by the Somerset Safeguarding Adults Board (SSAB), which sets out the findings of their thematic review of homelessness.
This holistic review of safeguarding practice was commissioned to explore homelessness thematically. It relates to 3 men who are or were in receipt of care and support from statutory and voluntary agencies in Somerset.
A thematic review model was agreed to identify and share learning to improve future inter-agency practice and prevent deaths or serious harm in similar circumstances.
Mental health, chronic alcohol and drug dependency and/or long-term physical health conditions are central features in the lives of all 3 men and in agency responses towards them to differing degrees.
There is an acknowledged gap nationally in opportunities afforded to people affected by homelessness and multiple disadvantage to make their voices heard, so this review identifies lessons that could be implemented to support those experiencing homelessness and as well as promoting multi-agency ways of working to achieve this.
Its recommendations include:
- SSAB to seek assurance from the Council’s Adult Social Care and Housing teams about the availability and take up of legal literacy training available to frontline social workers and housing officers.
- SSAB to consider convening a meeting or event dedicated to how family, friends and partners are involved and supported when agencies are working with adults with mental health and substance use related care and support needs.
- Somerset Council to conduct a review of data and practice about safeguarding concerns raised about people experiencing homelessness.
- Somerset Council to work with their named Rough Sleeping Initiatives Advisor from the Ministry of Housing, Communities and Local Government (MHCLG) about the potential for resourcing a dedicated Homelessness Social Work role in the county.
- A written update from the Somerset Integrated Care Board about the implementation of the NHS England Inclusion Health Framework.
- SSAB to reach out to local Prison Governors to request a meeting to discuss HM Prison and Probation Service input in adult safeguarding arrangements, operationally and strategically, specifically related to discharge planning for highly vulnerable adults.
- To monitor implementation of the recommendations in the Joint Ministerial Letter of May 2024, SSAB to make homelessness a strategic priority in the Board’s next strategic plan.
- SSAB to request a presentation from the Council’s Public Health team on the implementation of the 2024-29 Suicide Prevention Strategy in relation to the support available to high-risk groups such as those experiencing homelessness, living with addiction and neurodivergent adults.
Professor Michael Preston-Shoot, Independent Chair of the SSAB, said:
These reviews are not about apportioning blame, they are about making sure lessons are learned and improvements made. Somerset Safeguarding Adults Board sought to explore this in some detail in relation to 3 people, who were experiencing multiple exclusion homelessness to review the support of agencies working across Somerset, to learn lessons from the circumstances. It is clear that there is no one typical person who is experiencing homelessness.
The learning from this review is put into effective practice through 4 domains – direct work with individuals, the team around the person, organisational support for the team, and governance.
We are grateful to those who knew or worked to support these individuals for their contribution towards the review, and for their insight towards what might have made a difference in these cases.
In addition to the recommendations made by the review author, the Somerset Safeguarding Adults Board has agreed that it will arrange an event, which will focus on homelessness and how we can work together to reach those experiencing it.
The Safeguarding Somerset Adults Board is made up of all the organisations which have a role in preventing the neglect and abuse of adults, including:
- Somerset Council
- Somerset NHS Integrated Care Board
- Avon and Somerset Police
- National Probation Service
- Somerset NHS Foundation Trust
- South Western Ambulance Service
- NHS Foundation Trust
- Registered Care Provider Association
- Healthwatch Somerset
For more information about the SSAB and a copy of the report visit the Safeguarding Somerset Adults Board website.
