Alex’s insight into “His brain injury was missed, it led to his death”: brain injury case managers’ experience of safeguarding research article.

Review written by Alex Price
Brain Injury Case Manager

“His brain injury was missed, it led to his death”: brain injury case managers’ experience of safeguarding

Research article written by Alyson Norman, Abigail Parsons, Joshua Deacon, Jo Clark-Wilson & Mark Holloway

“Safeguarding is everybody’s responsibility” is a statement repeatedly reinforced throughout social work training and professional practice. In children’s services, high-profile safeguarding cases such as Victoria Climbié and Baby P shaped professional consciousness for decades, embedding a shared understanding of risk, accountability, and system failure. In contrast, there has been no equivalent Safeguarding Adult Review where acquired brain injury (ABI) has captured the same collective attention, despite mounting evidence that missed or misunderstood brain injury can have fatal consequences.

Adults with ABI often sit within safeguarding grey areas. They may appear articulate, physically independent and outwardly capable, while experiencing significant impairments in insight, judgement, memory, emotional regulation and vulnerability to exploitation. As a result, risk is frequently underestimated or misinterpreted. For professionals working within brain injury services, safeguarding concerns are not always exceptional events but recurring patterns, reflected in Safeguarding Adult Reviews such as Tom (2017) and Jack (2024), where vulnerabilities linked to brain injury were poorly understood and outcomes were tragic.

Safeguarding in the context of ABI is rarely a single, clearly defined incident. More often it presents as subtle, cumulative harm: neglect through inaction, erosion of dignity, poor-quality care, or a gradual drift away from person-centred practice. Domestic abuse, coercive control, cuckooing and exploitation are recurring concerns. Individuals with ABI may struggle to recognise controlling behaviours, set boundaries, or assess risk. They may minimise harm, protect perpetrators, or lack the cognitive and emotional resources required to disengage from abusive situations.

This complexity mirrors wider safeguarding challenges, particularly in cases of domestic abuse where victim-blaming narratives such as “why don’t they just leave?” persist. Brain injury adds a further layer, particularly where executive functioning and capacity are impaired. Even when capacity is assumed, it is not always robustly assessed or revisited as circumstances change.

The 2025 research by Parsons et al. is therefore timely and significant. It highlights case managers’ experiences of safeguarding issues arising predominantly from cognitive and behavioural impairments, identifies inconsistent capacity assessments, and points to limited professional understanding of brain injury, including phenomena such as frontal lobe paradox. Crucially, the research underscores the protective role of specialist case management and advocacy — raising serious concerns for individuals with ABI who lack access to such support.

Reflecting on this research reinforces the urgency of improving education and awareness of ABI across health and social care systems. While trauma-informed practice is increasingly embedded within local authority services, ABI training remains non-mandatory, despite over 1.3 million people living with the long-term effects of brain injury in the UK. Many more remain undiagnosed. Brain injury rarely exists in isolation; it intersects with mental health difficulties, substance misuse, poverty and social exclusion, increasing the risk of individuals falling between services.

If safeguarding truly is everybody’s responsibility, then brain injury must be recognised fully in the context of safeguarding and not merely acknowledged. The phrase “his brain injury was missed; it led to his death” should serve as a call to action — demanding better assessment, improved inter-agency understanding, and recognition of ABI as a critical safeguarding issue rather than a peripheral clinical concern.

Read the article here

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