A REPORT following the death of a 76 year-old Pembrokeshire woman has identified a series of failings in the way vulnerable adults should be protected.

A serious case review (SCR) into the death of the woman - identified only as Adult A in the report - was carried out four years after her death in May 2012.

An Executive Summary of the SCR was published last week.

It states that the woman died at Withybush Hospital following surgery for incision and drainage of an abscess.

She had previously been living at Belmont Court Nursing Home, Tenby and had been subject to a series of admissions to hospital.

The report states that safeguarding concerns were raised about Adult A when she was first admitted to hospital.

The key findings stated that social services, Hywel Dda health Board, Care and Social Services Inspectorate Wales (CSSIW) and to a lesser extent the police, "repeatedly failed to adhere to basic principles contained within the Wales guidance regarding the protection of vulnerable adults."

It adds: "And there was a lack of understanding by professionals from all agencies of what the adult protection processes were."

The findings also stated that it was evident that the adult protection procedures were not appropriately implemented, lessons needed to be learned about acting upon identified problems and concerns raised about a lack of transparency in record keeping.

Hospital based processes could have been strengthened to recognise safeguarding alerts when Adult A was subject to repeated admissions to hospital from Belmont Court, the report states.

The report was commissioned by the Pembrokeshire Adult Protection Committee, which accepts a series of recommendations made within the report.

The Executive Summary is available here.