Safeguarding Adults Alert Form
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TO GO OUT TO PROVIDERS SAFEGUARDING ADULTS ALERT FORM Guidance Please ensure that all staff are aware of, and following, the Safeguarding Multi-Agency procedure that can be found along with a copy of this form on the Wigan Safeguarding Website http://www.wigan.gov.uk/Resident/Health-Social-Care/Adults/Report-abuse-orneglect-of-a-vulnerable-adult.aspx Please also refer to the Safeguarding Alert Guidance Document and Table. Please ensure that all parts of the form are completed If your alert is urgent and requires immediate action, please contact Initial Assessment Team on 01942 828777 to give main details of alert and follow up with this form This form should be completed for ALL CASES OF ABUSE INVOLVING VULNERABLE ADULTS IF YOU HAVE ANY CONCERNS THAT A CHILD OR YOUNG PERSON IS AT RISK OF ABUSE THEN YOU SHOULD CONTACT CHILDREN’S DUTY TEAM ON 01942 828300 1. Details of adult at risk Name of Adult at Risk ………………………….………………………………………… D.O.B. ……………………………………………………………………………….............. Address ……………………………………………………………………………………... NHS Number ……………………………………………………………………………….. Funded by: Wigan Other LA Is the person in a step down bed? 2. CHC Self Funder YES/NO Reason for alert ………………………………………………………………………………….................... ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. ……………………………………………………………………………………………….. 3. Date of incident ……………………………………………………………….. 4. Who is the alleged source of risk FAMILY MEMBER STAFF MEMBER ANOTHER VULNERABLE ADULT OTHER Name ……………………………………………………………………………..……….. Position/Relationship to Victim ……………………………………………………… D.O.B. (If known) ………………………………………………………………………... Organisation (if appropriate) …………………………………………………………. Address (If known) ……………………………………………………………………... 5. 6. Has information been shared with appropriate people Have family of victim been informed (If approp.) Yes No Have family of perpetrator been informed Yes No Have CQC been informed Yes No Have police been alerted to a crime Yes No (If approp.) Date ……………………………………………………………………………………….. Crime No. ………………………………………………………………………………… Police Officer dealing ………………………………………………………………….. 7. Was medical intervention required Yes No Visit by GP ……………………………..………… Date ……………….……… Taken to Hospital ……………………………….. Date …………………….… Returned from Hospital ………………………... Date ……………….……… Reason: If none of the above occurred what injuries were observed and action taken: ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………….. 8. Does the adult at risk have capacity to consent to referral Yes 9. No If adult at risk has capacity are they consenting to referral Yes No 10. Is there need to override consent due to potential duress or wider public interest Yes 11. No Is this an allegation of abuse which requires a referral and investigation under wigan’s safeguarding adults multi-agency procedures Yes No Category: Physical Sexual Psychological/Emotional Financial/Material Neglect/Acts of Omission Institutional Discriminatory abuse of individual rights a) If YES, please give more information: ………..……………………….…... …………………………………………………………………………………….. ……………………………………………………………………………….……. …………………………………………………….....…………………………… b) If NO, why not and what action has been taken to prevent this happening again (even in this case the form should be sent to CDT): …………………..………………..……………………………………………… ..........………………………………………..…………………………………… …………………………………………………..………………………………. Completed by: Print Name ………………………………………………………………………………….. Designation/Role ………………………………………………………………………….. Signature …………………………………………………..….Date ……………………… Contact Telephone number ………………………………………………………………. Submitting the form On completion of this form please save it to your computer. To submit the form you need to upload it using the link below: https://rylands.wigan.gov.uk/SafeguardingAdultAlertForm/ Please retain a copy of this word document on your computer for your records. Please note: In certain circumstances it may be necessary in the interests of the prevention or detection of crime or to further the function of protecting vulnerable adults to make the contents of this document available to the civil and criminal courts, solicitors, psychiatrists, other local authority social workers or other professionals involved in the care and support of the vulnerable adult.
