​​​This Learning Report summarises the findings and recommendations of the Serious Case Review: Mr Arthur, which concerns the death in 2014 of an adult man.

Serious Case Reviews into cases are commissioned by the Safeguarding Adults Partnership Board where abuse or neglect of an adult is known or suspected and the individual has died or been seriously harmed and there is serious cause for concern about the way in which agencies have worked together to safeguard an individual.

They are intended to establish whether lessons can be learned, identify those lessons and to improve inter-agency working and promote the welfare and safeguarding of adults.