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.