Sussex Adult Death Protocol

Version: 3
Date published: December 2025
Review due: December 2028

Foreword by the Independent Chairs

The East Sussex, Brighton and Hove, and West Sussex Safeguarding Adults Boards are resolute in assuring and developing the way in which agencies work together to prevent and protect those at risk from abuse and neglect. Through audit, Safeguarding Adults Reviews and scrutinising the safeguarding system, we share good practice and highlight where things have, or may, go wrong and to mitigate future risks where we can in supporting people.

Despite this, sadly and tragically, sometimes, vulnerable people do experience abuse and/or neglect which can cause or contribute to their passing. When this happens, we, families, and the public expect agencies to collaborate without delay to establish what has happened, whether any crime has been committed and whether there are others at risk who need safeguarding.

Our learning from cases of this kind, is that existing inter-agency systems have not been best equipped to respond in the timely and collaborative approach required. In response, we have together, invested with Sussex Police leading, in the development of a pan-Sussex multi-agency protocol to address this important area.

The Adult Death Protocol is the result of the joint efforts of the partnership across Sussex agencies who have contributed with great enthusiasm and commitment to creating, this pan-Sussex Adult Death Protocol. It is clear and pragmatic in how it brings key agencies together in the early investigation phase which, we know from experience, is critical in all safeguarding enquiries. The protocol will essentially also, help professionals at all levels, in these difficult situations and significantly, help assure and support people who use services and their families who, are at the forefront of all that we do.

As with any protocol published by the Safeguarding Adults Boards, we will keep this under review to ensure it is effectively adopted and its objective of achieving effective multi-agency working, to identify potential criminal offences and protect others from abuse or neglect, is met.

Annie Callanan, Independent Chair, West Sussex Safeguarding Adults Board and Seona Douglas, Independent Chair, Brighton & Hove and East Sussex Safeguarding Adults Boards

Foreword by Superintendent of Public Protection, Sussex Police

The Sussex Adult Death Protocol is a significant advancement in the multi-agency response to unexpected adult deaths where abuse or neglect is suspected. It provides a structured framework for statutory partners to collaborate effectively, ensuring that such cases are managed with clarity, consistency, and in accordance with legal and procedural standards.

This protocol has been developed through extensive partnership working across Brighton & Hove, East Sussex, and West Sussex Safeguarding Adults Boards. It reflects a shared commitment to safeguarding adults and to ensuring that agencies respond promptly and proportionately when concerns arise regarding the circumstances of a death.

The protocol sets out clear criteria and processes for referral, triage, and joint agency decision-making. It supports the early identification of safeguarding risks, facilitates appropriate criminal and coronial investigations, and promotes transparency and accountability in professional practice.

Above all this protocol ensures vulnerable adults receive the multi-agency service these so deserve, putting them at the centre of what we do.

Andy Harbour, Superintendent – Public Protection, Sussex Police

Introduction and purpose of protocol

The circumstances in which an unexpected adult death takes place, where there is a suspicion or it is known that abuse or neglect was involved, can be challenging and complex to navigate with partner agencies having different roles and responsibilities in response to the death.

The joint work undertaken to develop this protocol by the Safeguarding Adults Boards across Brighton & Hove, East Sussex and West Sussex reflects a commitment to effective partnership working and information sharing across Sussex and to ensuring a rapid, coordinated response to unexpected adult deaths involving abuse and neglect.

This protocol is for adoption, information and application by the partner agencies of the Brighton & Hove, East Sussex and West Sussex Boards. You can find details of these agencies below:

• Brighton & Hove Safeguarding Adults Board | Members
• East Sussex Safeguarding Adults Board | Members
• West Sussex Safeguarding Adults Board | Our members

The adult death protocol provides a framework for establishing an agreed standard between partners to:

• ensure an effective and consistent multi-agency response that will support agencies of the Sussex Safeguarding Adults Boards to meet the requirements of legislation, national and local guidance and practice standards around appropriate responses to unexpected adult deaths involving abuse and neglect.
• ensure clarity and consistency of procedures across organisations of the Sussex Safeguarding Adults Boards.
• develop arrangements that support efficiency in partnership working to identify potential criminal offences or when there is a need to conduct investigations into unexpected adult deaths.
• focus on a commitment to effective information sharing which can lead to improved outcomes in relation to investigating unexpected deaths.

This protocol is based on existing legal mandates and has drawn as appropriate on the current child death review process. It should be used in conjunction with the Sussex Safeguarding Adults Policy and Procedures and the Sussex Information Sharing Guide and Protocol.

Scope and criteria

The purpose of the Adult Death Protocol is to identify deaths of adults within the community or care settings where there is an indication of abuse and neglect. The abuse or neglect is not only when it relates to the circumstances of their death but can also be recent abuse or neglect in their lives.

Definition of an adult for the purpose of this protocol

This is set out in Sections 42 to 47 of the Care Act in relation to adult safeguarding and applies to any person aged 18 years or older who:

• has needs for care and support (whether or not the local authority is meeting any of those needs);
• is experiencing, or is at risk of, abuse or neglect;
• as a result of those care and support needs, is unable to protect themselves from either the risk of, or the experience of, abuse or neglect.

The Adult Death Protocol applies to the following criteria:

• an adult dies in unexpected or unnatural circumstances, and;
• there is a suspicion, or it is known, that abuse, or neglect was a contributory factor in their death, and;
• the abuse or neglect is believed to have been caused by a third party.

This protocol has been created to compliment these statutory responsibilities by encouraging early information sharing and collaboration between the three statutory agencies.

Any situation involving a suspected homicide will not be covered by this protocol, and the homicide investigation and Domestic Abuse Related Death Review (DARDR) takes precedence.

DARDRs take place when the death, including a suicide, of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a relative, a household member, someone the person had been in an intimate relationship with.

A DARDR’s purpose is to review the circumstances leading to the death, consider where responses can be improved in the future, identify any best practice to share.

It is important that dependent on the initial presentation of the circumstances of the death that all appropriate processes including the need for DARDR referral are fully considered and acted upon, with referrals made in a timely manner. If concerns regarding domestic abuse emerge at any stage, the need for a DARDR referral should be reviewed.

Where the case is initially treated as a suspected homicide by police but subsequent enquiries reveal that the death is non-suspicious and no longer being treated as a suspected homicide, if the Adult Death Protocol criteria is met, the protocol should be followed.

The protocol does not replace any internal policies and procedures of partner agencies. Staff should also refer to relevant policies and guidance of their own organisation in conjunction with this document.

Raising a referral for the Adult Death Protocol

When an adult dies and there is suspicion, or it is known, that they suffered from recent abuse or neglect or that it was a contributary factor in their death the agencies with immediate primary responsibility are the police and coroner. Coroners are independent judicial officers who are responsible for investigating violent, unnatural, or unexplained deaths. The police response will depend on which criminal offences are suspected and on other factors such as whether anyone else is considered to be at immediate risk of harm.

Given the primacy of the police being contacted in the event of an unexpected adult death, the police will lead on reviewing and triaging any information submitted by an agency about an unexpected adult death to confirm whether the Adult Death Protocol should be used.

Professional judgement in the context of an Adult Death Protocol referral is crucial for ensuring concerns relating to the nature of an adult’s death are appropriately referred and managed. It allows practitioners to consider the specific circumstances of a case and potentially escalate it to the panel even if it doesn’t meet the standard referral criteria. This means that if a professional has serious concerns, they can use their expertise to advocate for the referral. Consideration should be given to discussing with the organisation’s safeguarding lead prior to making the referral.

Any agency or professional can make a referral for the adult death protocol by completing and emailing the Adult Death Protocol Referral Form (Word, 267KB) to the relevant Police Multi-Agency Safeguarding Hub (email below) with a summary of the case including details of abuse and/or neglect, the key information of the adult and contact details of the known agencies involved:

• West Sussex: WS_PSH@sussex.police.uk
• East Sussex: EastSussexMash@sussex.police.uk
• Brighton and Hove: Mash@sussex.police.uk

Alternatively, you can contact Sussex Police on 101 or contact Sussex Police online for referrals over weekends/evenings and 999 in an emergency. The contact centre will record referral details and undertake an initial triage to identify if the criteria for the use of the Adult Death Protocol are met.

These details will then be passed to first line police responders who will visit the location of the deceased with an ambulance crew. If the Detective Sergeant at the scene assesses that the adult death protocol criteria are met, the details are passed on to the Multi-Agency Safeguarding Hub (MASH) who will contact the relevant statutory partners to assess whether the Adult Death Protocol criteria applies and if an Initial Joint Agency Meeting (IJAM) will be arranged. Further details of this process are set out within the flowchart on the next page. Refer to Appendix i for templates to support this process.

Overview of Adult Death Protocol if police are in attendance and immediate action needed

The following process should be used if police are in attendance and immediate action is needed.

Immediately

Police or professionals are in attendance of a death which they believe fits the Adult Death Protocol:

• The identifying agency contacts Sussex Police contact centre via 101 to make a referral for the Adult Death Protocol to be triggered.
• The contact centre conducts initial triage to identify if the Adult Death Protocol criteria are met.
• The contact centre notifies first line police responders to attend location of deceased.

Ambulance and police attendance

Ambulance and police attend location of the deceased:

• Health professional/clinician confirms death.
• First line responders draw on professional judgement and use Adult Death Protocol aide memoir. If they suspect abuse or neglect by a third party, a detective Sergeant (DS) attends and conducts initial investigative assessment.
• If DS believes Adult Death Protocol criteria are met, a Detective Inspector (DI) Crime Scene Investigators (CSI) and the coroners Officer attend and conduct a joint examination of the deceased with the attending medical practitioner.
• Consider safeguarding risk to other adults and/or children and raise a safeguarding concern if required.
• Engage staff/family and explain Adult Death Protocol process.
• If a homicide is suspected, then the homicide process takes primacy.

Initial Joint Agency Meeting

Attending DI notifies MASH DI to arrange Initial Joint Agency Meeting (IJAM) IJAM to have representation from statutory partners:

• Police
• NHS Sussex Integrated Care Board
• Adult Social Care and Health
• and any other agency by invitation as required

Within 24 hours

IJAM chaired by MASH DI:

• Initial information sharing, risk assessments, action plan (including consideration of risk to other adults/children).
• Confirm lead agency.
• Referring agency completes the Adult Death Protocol Referral Form.
• Consider involvement from any other relevant agency and plan to request additional information.
• Confirm other enquiry/investigation processes.
• Consider if the criteria for a Safeguarding Adults Review referral may be indicated.

Overview of Adult Death Protocol when a referral is received

The following process should be used if an Adult Death Protocol referral form is received into the Multi-Agency Safeguarding Hub. Refer to Appendix ii for more information.

Immediately

Unexpected adult death in which the Adult Death Protocol criteria are indicated by agency:

• The identifying agency contacts Sussex Police MASH by completing the Adult Death Protocol Referral Form with the nature of referral and concerns.
• MASH DI is notified and makes contact with both the Adult Social Care and Health Safeguarding leads and the NHS Sussex Integrated Care Board (ICB) safeguarding team should be involved in these initial discussions to discuss if Adult Death Protocol criteria is met.
• Consider safeguarding risk to other adults and/or children and initial immediate action to safeguard if necessary (lead to be identified).
• Discussion to be held on most appropriate agency to lead the Adult Death Protocol; this should either be agency who has identified concerns or has most information about the adult.

Police actions

Police to ascertain location of deceased and consider Fast Track Actions:

• Police make contact with HM Coroner and inform them of concern.
• Location of deceased is identified, and any Fast Track Actions (such as blood samples or photography) is considered and discussed with HM Coroner’s officer.
• Police secure copy of cause of death including details of post mortem if one took place.
• If a homicide is suspected, then the homicide process takes primacy.

Within 72 hours

Within 72 hours (working) or as soon as practicable initial meeting (IJAM) to be convened. If agreed by safeguarding leads and no immediate safeguarding concerns have been identified the initial meeting can fall outside of 72 hours but must be convened within 5 working days in order to allow for requisite professionals to be in attendance. The IJAM should be chaired by the police:

• Initial information sharing, risk assessments, action plan (including consideration of risk to other adults/children).
• Agencies to supply chronologies, if practicable, or similar information to avoid changes later.
• Consider involvement from any other relevant agency and plan to request additional information.
• Confirm other enquiry/investigation processes.
• Discuss risk to other adults and safeguarding plans/reassurance.
• Consider if the criteria for a Safeguarding Adults Review referral may be indicated.
• Adult Death Protocol Referral Form outcome section to be completed during the IJAM to include if criteria has been met/not met with reasoning and agreed outcome/actions and which agencies will take these forward.
• If a second meeting is required confirm chairing arrangements with lead agency.

Within 6 weeks

• Police will investigate any potential criminal offences.
• Coroner will undertake preliminary and final post-mortem examination report.
• Any other enquiry or investigatory process will continue, including a review of health and social care information.

Actions undertaken following meeting:

• Agencies follow own internal processes to review the circumstances of the death.
• Appropriate feedback of outcomes of local case discussion to family and interested parties including the referring agency.
• Further consideration if the criteria for a Safeguarding Adults Review referral may be indicated.

Follow-up meeting

Follow up meeting to be arranged by lead agency if appropriate, to review learning from the case; confirm any further case management actions; make strategic recommendations. Any recommendations made at this meeting are the responsibility of the owning agency to progress.

Legal considerations

There is a range of legislative frameworks and investigatory processes that may need to run concurrently with any criminal investigation.

Sections 42 to 47 of the Care Act 2014 set out a clear legal framework for adult safeguarding and are supported by the Care and Support Statutory Guidance.

A referral for a Safeguarding Adults Review (SAR) may be appropriate where there are concerns that an adult has died as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. A SAR is concerned with ensuring learning and improvements in practice and is not about apportioning blame. The Sussex Safeguarding Adults Review Protocol sets out the approach to undertaking Safeguarding Adults Reviews across Sussex that follows both statutory guidance and local policies.

The Sussex Safeguarding Adults Policy and Procedures contains guidance around the interface between the safeguarding adults process and other investigations and reviews, including:

• Serious Incident Investigations
• Child protection and safeguarding procedures
• Learning Disabilities Mortality Review (LeDeR) Programme
• Safeguarding Adults Reviews

In situations where a crime has been, or may have been, committed it is important that any forensic evidence is preserved wherever possible. Further information on this is covered within chapter 2.4 of the Sussex Safeguarding Adults Policy and Procedures: Safeguarding and Criminal Investigations.

Effective multi-agency working

Given the complex nature of responding to situations involving an unexpected adult death, a coordinated multi-agency approach is essential to ensure effective information sharing and communication, a shared responsibility for assessing risks and agreeing an action plan.

The Sussex Adult Death Protocol adheres to the principles set out in the Sussex Information Sharing Guide and Protocol.

Working with families

When an adult dies unexpectedly and in suspicious circumstances, effective and appropriate communication with families is of the upmost importance and should be carried out in a respectful and sensitive manner.

In the vast majority of cases where someone dies unexpectedly, nothing unlawful has taken place. It must also be acknowledged, however, that in a small percentage of situations something unlawful may have taken place. This must not be forgotten. Safeguarding adults is everyone’s responsibility.

Providing support and care to the bereaved family from the earliest possible stage is a core component of the joint agency response and runs through all stages of the response. It is likely that the family of the deceased will be distressed and shocked.

At all times consideration should be given to the family’s wishes and beliefs, and how these can be accommodated within any statutory requirements. It is every family’s right to have their loved one’s death properly investigated. Families desperately want to know what happened, how the event could have occurred, what the cause of death was and whether it could have been prevented.

In the initial stages following the identification of an unexpected adult death, the police and coroner’s officer will be the main point of contact for family members. At the Initial Joint Agency Meeting (IJAM), responsibility as to which lead agency should provide ongoing information and coordinate appropriate care and support for the family will be confirmed.

Key considerations include:

• It is important to clearly explain the process and what is happening to family members, and provide facilities to contact friends, other family members and cultural or religious support.
• Professionals should express empathy with the family and respectfully use the deceased’s name and correct gender in all conversations. Sharing our humanity can make a real difference to families. Taking a trauma-informed approach to supporting family members, is key to managing wellbeing and preventing re-traumatisation.
• Consideration should be given to the capacity of the family to engage in the processes unfolding around them. Support from advocacy services should be considered where appropriate. Particular consideration should be given to issues of language, health or mental capacity. Further consideration must also be given to the faith and culture of the deceased and their family.
• Where English is not the family’s first language, every attempt should be made to provide a translation or interpreting service, including out-of-hours provision, for example through Language Line. Family members, particularly children, should not act as interpreters.
• Responsibility for providing ongoing information and coordinating appropriate care and support for the family is shared between the lead health or social care professional, police investigator and coroner’s officer. There needs to be clear liaison between these professionals as to who will take responsibility for each aspect of care and support.
• The family should be told at an early stage that, because their loved one’s death was unexpected, the coroner will need to be informed and there will need to be a police investigation. This must be explained to the family in a sensitive way, emphasising that these are routine procedures that are followed for an unexpected adult death.
• The purpose and process of the joint agency response should be explained to the family, emphasising that all professionals are working together to try to help them understand why their loved one has died and to support them. The family should be informed that, as part of this process, information will be shared with their primary care team, social services and other relevant professionals.
• The family should be informed that the coroner is likely to order a post-mortem examination. The family should be informed about the post-mortem examination, including the likely venue and timing, any arrangements for moving their loved one, and the likelihood that tissues will be retained during the post-mortem examination. This information should be provided in a sensitive and meaningful manner. As part of the explanation about the post-mortem examination given to the family, the lead health or social care professional or coroner’s officer should explain that tissue samples will be taken and that, following the coroner’s investigation, the family can then determine the fate of the tissue according to the Human Tissue Act 2004.
• The family should be made aware that it may take several weeks to secure the results of the post-mortem examination and for the coroner to come to a conclusion. Every effort should be made to keep the family informed at each stage of the process. The family should receive regular telephone calls from either the health or social care professional supporting the family or the coroner’s office to let them know how matters are proceeding.
• The family should be clearly informed of the names and contact details of the lead professionals responsible for the joint agency response, including the lead health or social care professional, police investigator and coroner’s officer. If it becomes necessary to transfer responsibilities between professionals, the family should be informed of this and introduced to any new professionals involved.
• The family must be given clear details of whom to contact, both in working hours and out-of-hours, should they have any questions or concerns.
• Under the Police and Criminal Evidence Act 1984, section 29, if the police investigator has suspicions that the death may be a crime, the law demands that the suspect’s rights are protected and certain legal restrictions apply in terms of how they can be spoken to, and by whom. This is particularly relevant where the possible suspect is a family member.

Initial Joint Agency Meeting (IJAM)

The IJAM is a crucial step within the Adult Death Protocol to provide a clear pathway to ensure the effective co-ordination between statutory partners and other relevant agencies involved.

The objectives of the IJAM are to:

• Ensure rapid information sharing and risk assessment (including risk to others).
• Confirm who will be the lead agency.
• Consider any other agencies involved and request information from them.
• Consider any other relevant enquiry or investigatory process and the timing of the same, including further police investigations, Section 42 safeguarding enquiry, Serious Incident Review, Learning Disabilities Mortality Review (LeDeR), Safeguarding Adults Review (SAR).
• Considerations around family members and carers, including views of others and how family or carers will be kept informed.
• Develop a multi-agency action plan with agreed timescales and details of who is leading on each action.
• Consider actions required regarding a media strategy.
• Confirm a communications strategy across senior agency representatives.

The IJAM will be set up via the Multi-Agency Safeguarding Hub (MASH) Detective Inspector (DI), who will liaise with the safeguarding leads for Adult Social Care and Health (ASCH) and the NHS Sussex Integrated Care Board (ICB) in the relevant area to agree attendees. As a minimum there should always be representation from the three statutory partners. The ICB will attend the initial IJAM and identify and delegate actions thereafter to the appropriate health provider organisations. Similarly, the senior manager representative from ASCH at the IJAM will identify and delegate follow-up actions as required to the relevant operational team. Additional agency representatives should be considered on a case-by-case basis. All agencies have a responsibility to attend. Where an individual cannot attend, they should inform the MASH DI and arrange for a representative of a suitable level of seniority from their organisation to attend.

Invitations and documentation for the meeting will be sent securely ahead of the meeting. Attendees should be familiar with their responsibilities and ensure they read all relevant material in advance of the IJAM. Statutory partners should ensure that appropriate information and intelligence gathering is conducted at the outset so that salient information can be shared at the meeting.

For instances where police are in attendance the IJAM should take place within 24 hours wherever possible. If the unexpected death is reported over a weekend or bank holiday the IJAM should be convened on the next working day.

If referral is made in by another agency or relates to a death which has not occurred within a week of the referral then IJAM to be convened within 72 hours (working) or as soon as practicable. If agreed by Safeguarding leads and no immediate safeguarding concerns have been identified the initial meeting can fall outside of 72 hours but must be convened within 5 working days in order to allow for requisite professionals to be in attendance

The IJAM can be at a physical however these will predominantly be arranged virtually on MS Teams in order to facilitate optimum attendance. The MASH DI will chair the meeting. All meetings are recorded and a transcript shared with all attendees who wish for a copy. Master copies of the transcripts will be hold on police Niche systems.

Follow-up meeting

The requirement to convene a follow-up meeting as part of this protocol should be considered at the IJAM to ensure that actions are monitored and reviewed and to consider any learning from the case. Any follow-up meeting should be convened within six weeks of the IJAM and will be chaired by the lead agency.

The follow-up meeting will involve not only consideration of further case-specific actions but broader systemic learning that may require strategic actions. In considering these recommendations, any agency which is identified to take forward an action will be responsible for progressing that work and for the respective governance and oversight attached to that action.

Complaints or disputes

Any complaint or dispute arising during the process of the Adult Death Protocol will be dealt with according to the lead agency’s complaints policy. For disputes in relation to health actions, this may well not be the NHS Sussex ICB but the appropriate health provider organisation identified at the IJAM.

The process outlined in the Sussex Escalation and Resolution Protocol provides for the escalation and resolution of such disagreements where an agency or professional has a concern with regard to a decision made by other professionals or another agency in relation to adult safeguarding and mental capacity within adult safeguarding.

Review of this protocol

The protocol will be reviewed by representative(s) nominated by the Brighton & Hove, East Sussex and West Sussex SABs on agreement as to the regularity and will also be reviewed in the event of any relevant change in law (with advice being taken as necessary), or changes in the circumstances relevant to the agreement.

Reviews will take place every three years unless significant changes are required. Evaluations will take place periodically to ensure effective use of the Adult Death Protocol by Partners. Recording of Adult Death Protocol cases will be maintained and monitored by Sussex Police.

Appendix ii: Process for the review of Adult Death Protocol referral received into MASH by referring agency

Step one – Adult Death Protocol referral assessed by police MASH admin and Niche Record created. Adult Death Protocol referral submitted to MASH Detective Inspector for Review

Step two – MASH Detective Inspector reviews referral and checks police systems for any existing material relating to the death. Contacts coroners officer or bereavement team if Cause of Death not known.

Step three – MASH Detective Inspector emails a copy of the referral to the Head of Safeguarding for the requisite Adult Social Care authority and the ICB safeguarding adults nursing Team. Agencies then review to decide if Adult Death Protocol criteria is met (short meeting via Microsoft Teams can be convened if required).

Step four – If it is agreed that the threshold is met for Adult Death Protocol then agencies agree a date for initial IJAM to be held. Adult Social Care, NHS ICB & Police decide which other agencies are required at the meeting. Once date is agreed MASH Detective Inspector will create and send out teams invite.

If it is decided that the criteria for Adult Death Protocol is not met MASH detective Inspector will email initial referrer with a rationale as to why the criteria for Adult Death Protocol has not been met.

Step 5 – IJAM held or case closed.