Safeguarding Adults Enquiry Form

This form should be completed as fully as possible in order that
robust decisions can be made about the progression, or otherwise,
of the Safeguarding Adults Enquiry.
Person Role of Person:
completing
the form:
Date of Organisation:
referral to
Adult Social
Care:
Phone Type of service:
number:
Details of incident/suspected/actual abuse or neglect
Date of Who reported
alleged the
incident: alert/concern?
Time of Date of report:
alleged
incident:
Where did the incident
occur?
Details of the adult at risk
Name: Date of Birth:
Tereza
Lazo
Telephone: Ethnicity:
Address:
What is the adult’s primary reason for needing care and
support? (please tick)
Physical Sensory support: Support with
support: memory and
cognition:
Learning Asperger’s Autism support:
disability syndrome
support: support:
Mental health Social support No support
support: (includes support reason:
for
carers/substance
misusers):
Other health Pleas
condition: e
specif
y:

Any other
details about
the adult at
risk:
Details of the alleged perpetrator (where relevant)
Name: Relationship to
victim:
Date of birth: Ethnicity:
(1) Please give a detailed description of the incident (including times), all
people involved, witnesses and any other comments you feel are
relevant. If the concern relates to physical abuse please provide a body
map. (Maximum 200 words)
Tereza is an old woman of age 64 years, suffering from diabetes. Her physical
condition is poor, she has physical immobility, and she has difficulty to move in her
flat and prefers to sit on a chair surrounded by dirt all over. Tereza’s General
practitioner expressed concern regarding Tereza’s personal negligence which is a
form of self-neglect abuse. I am a health care professional who went to attend Tereza,
however I was not allowed to enter into her flat. She opened the door and she had an
unkempt appearance, her clothing was filthy with matted hair, she had sores on her
ankles which were infected. She looked frail and incapable to move, her hands were
shaking and she told me to drag a chair for her to sit at the doorway. She could not
reach out for a chair for herself due to physical immobility. She asked me to get her a
chair, however she wanted to care for her infected sores on her ankle.
bjb
Type of abuse (tick all that apply):
Physical: yes Sexual Psychological/emoti
onal
Financial/mate Neglect/omis Discriminatory
rial sion
Organisational Self-neglect Domestic
/institutional yes abuse/violence:
Modern Radicalisatio Other