Significant Case Review - P19

Published on Thursday 25 November 2021

A Significant Case Review entitled P19 has been published today (Thursday 25 November 2021) by the Angus Adult Protection Committee (AAPC).

A resident of Angus, P19 died as a result of end-stage cancer in December 2018, aged 50.

P19 had been identified as an “adult at risk” in August 2018 and there was involvement by a number of agencies and services prior to their death.

The review focuses upon the four months prior to P19’s death. It was commissioned by Angus Council on behalf of the Angus Protecting People Chief Officers Group, following a recommendation from the Angus Adult Protection Committee, to identify and maximise any opportunities for local and national learning and improvement.

P19’s family has contributed to this review and been kept updated throughout the process. P19 is not publicly identified in this review and the family very much want to retain their anonymity.

The Angus Adult Protection Committee’s Independent Chair, Ewen West, said: “The Committee has oversight of the crucial services provided to vulnerable adults in Angus to ensure best practice. When best practice is not delivered, the Committee will review, intervene, challenge and ensure that Services can and do change and improve.

“Uppermost in the minds of everyone that provides care and service to our vulnerable adults in Angus must be the health, wellbeing and dignity of those people they are seeking to support. When the circumstances of P19 were referred to the Committee, they were viewed with the utmost priority. It was clear that a Significant Case Review was necessary to fully establish what had occurred and where any and all learning and improvement could be made.

“What has resulted is that a large number of recommendations have been proposed and all have been fully accepted by the Committee and the Angus Chief Officers Group. A number of the recommendations have already been acted upon and the AAPC will continue regular monitoring of these recommendations to ensure that each and every required action is put in place.

“This review makes clear that support from services must never be so inflexible that it cannot adapt to the needs of the individual, or their unique circumstances. Care and anticipatory care must always be undertaken in a holistic, person-centred way.

“The circumstances faced by professionals in this particular situation were very complex. It is clear there was a genuine effort to engage and support P19 and a number of those involved were and continue to be emotionally affected by those circumstances.

“P19 had advanced bowel cancer and no one identifiable action would have changed that. But very sadly, P19 died without having their needs fully met or anticipated by the Services surrounding them.

“On behalf of the AAPC, I wish to express my sincere condolences to the family for their loss and to thank them for the contribution they have made in the preparation of this report and its findings.”

Chief Superintendent Phil Davison, Chair of the Chief Officers Group for Angus since July 2021, said: “The Chief Officers Group has acknowledged the findings and accepts all of the recommendations included within the report.

“It is recognised that improvements in a number of areas have already progressed. These include strengthening information sharing and monitoring procedures, making sure the right people are involved at the right time according to a person’s individual needs, and clearer guidance to all partners on the referral of cases.

“The Chief Officers Group remains committed to continuous improvement in order to develop and maintain effective holistic services for people at risk of harm in Angus. Our thoughts are with the family at this time.”

Gail Smith, Chief Officer, Angus Health and Social Care Partnership said: “I want to publicly apologise on behalf of Angus Health and Social Care Partnership for our failings in the care and treatment of P19.

“We take the findings of the Significant Case Review very seriously and accept all of the recommendations. I have written to P19’s family to unreservedly apologise for our failings. I have assured them that we are taking immediate steps to act upon the learning of this case and be relentless in our efforts to improve the quality and consistency of our care as a result of this.

“I acknowledge that this was a very complex situation for all staff involved but we let P19 down and they did not receive the care they had a right to expect. We take our responsibilities for caring and supporting others very seriously. I am determined that lessons will be learnt about how we provide care and support to others, and particularly with vulnerable individuals."

Claire Pearce, Director of Nursing and Midwifery in NHS Tayside said: “On behalf of NHS Tayside, I would like to apologise to P19's family for the failings identified in the care provided to P19 and our thoughts remain with them.

“We fully accept all recommendations in the report and will continue to work with Angus Health and Social Care Partnership, Angus Council and Police Scotland to ensure all learning from the issues raised is shared across agencies and together we continue to make the necessary improvements to services supporting the most vulnerable people in our communities.”

AAPC Significant Case Review P19 and its Executive Summary are available on this website via

Useful links to information relating to adult protection and protecting someone from harm are available on the Angus Health and Social Care Partnership webpages.

There is also information on a range of websites, helplines, local and national support groups which focus on mental health and wellbeing can be accessed via NHS Tayside’s Mental Health & Wellbeing Resources


The Angus Adult Protection Committee has an independent chair and comprises of a range of statutory, private and voluntary organisation representatives.

The committee is responsible for ensuring agencies work together to protect adults who may be at risk of harm.

The committee performs a number of crucial functions in Angus including the co-ordination of training for professionals and other staff, the development of policies, procedures and protocols, ensuring the effectiveness and quality of local adult protection services through continuous improvement and the provision of public information about adult protection.

It comprises Angus Council Children, Families and Justice Services; Angus Council Housing Service; Angus Health and Social Care Partnership; NHS Tayside; Police Scotland; Scotland Fire and Rescue Service; Scottish Ambulance Service; Independent and Private Care Providers (representative); General Practitioners (representative); Angus Independent Advocacy; Angus Carers.


Angus Health and Social Care Partnership manages all operational adult health and social care services in Angus through the Chief Officer. The Chief Officer acts on behalf of the Chief Executive of Angus Council and the Chief Executive of NHS Tayside. The Chief Officer of Angus HSCP ensures that all decisions made by the Angus Integration Joint Board are delivered.

Services operated by Angus HSCP include unplanned admissions to hospital; Primary care services, including GPs and community nursing; Allied health professionals, for example physiotherapists and occupational therapists; Social work assessment; Social work services for adults and older people; Services and support for adults with physical disabilities and learning disabilities; Community mental health services; Community dental, ophthalmic and pharmaceutical services; Support for carers.


Angus Chief Officer Group for Public Protection (COG) brings together the Chief Officers from Angus Council, NHS Tayside, Police Scotland, and Angus Health & Social Care Partnership to provide strategic leadership in developing effective public protection services for people at risk of harm in Angus.

Individually agencies are responsible for the public protection services delivered by our own organisations. Collectively, they are responsible for developing and delivering the best services possible through partnership working.