Belfast Health & Social Care Trust Concedes Unlawful Safeguarding Review in High Court Challenge

The Belfast Health and Social Care Trust has conceded that a safeguarding investigation into vulnerable adults was unlawful, following a successful High Court challenge brought by Phoenix Law on behalf of the mother of a resident.

This landmark judicial review in Belfast highlights critical failures in adult safeguarding procedures in Northern Ireland and reinforces the right of families to challenge unlawful investigations.

The case arose from a Serious Adverse Incident (SAI) Review launched in October 2021 after widespread safeguarding concerns were raised by staff and families at a residential care facility.

These concerns involved vulnerable adults with intellectual disabilities, including former residents of Muckamore Abbey Hospital, a site already subject to significant public scrutiny regarding safeguarding failures.

Despite the seriousness of the allegations, the Trust’s investigation was affected by:

• Extensive delays
• Procedural breaches
• Failure to follow Trust and Regional SAI guidance

A review that should have been completed within 12 weeks instead took nearly four years to conclude. Throughout this period, the client – represented by Phoenix Law Belfast solicitors – was repeatedly promised an opportunity to contribute to the review. That engagement never took place.

When the SAI report was eventually published in May 2025, it failed to properly address the safeguarding concerns it was established to investigate.

Instead, the report:

• Made critical findings about families
• Failed to provide those families with an opportunity to respond
• Did not adequately explain repeated safeguarding referrals
• Offered no clear accountability for failures in care

Families were left without answers about how serious safeguarding issues were allowed to persist.

Phoenix Law Belfast initiated judicial review proceedings to challenge the lawfulness of the SAI review and ensure a proper investigation into the care provided.

During the case, additional concerns were raised by:

• Regulation and Quality Improvement Authority
• Strategic Planning and Performance Group

Just days before the High Court hearing, the Belfast Trust conceded that:

• The delay in completing the review was unreasonable
• There had been a failure to properly engage with the family

The High Court subsequently quashed the SAI review and report in full.

Following the legal challenge, the Belfast Trust has now committed to:

• Conducting a new investigation through an independent panel
• Identifying systemic failures and safeguarding shortcomings
• Ensuring lessons are learned to prevent recurrence

The Trust has also introduced a Family Engagement Practitioner role to improve family involvement in future safeguarding reviews.

Statement from Phoenix Law Belfast

Victoria Haddock, solicitor at Phoenix Law, said:

“It is deeply concerning that legal action was required to secure a lawful review into serious incidents involving vulnerable adults, particularly in the context of increased scrutiny in the wake of the Muckamore Abbey Hospital Inquiry.

SAI reviews are intended to identify what went wrong and prevent recurrence. In this case, that process failed entirely.

This outcome is legally significant. Previous case law limited the ability of families to challenge SAI reviews. This case demonstrates that such reviews are not beyond scrutiny and can be successfully challenged through judicial review in Northern Ireland. It sends a clear message that families must not be excluded from investigations into the care of their loved ones.

In the time that elapsed in this case, 20 SAI reviews could have been completed. When the processes designed to investigate failures fail, what trust do families have in ensuring their loved ones are protected. What is particularly troubling is how reminiscent these failures are of the very issues that led to the Muckamore Abbey Inquiry, raising serious questions about whether lessons have truly been learned”.

Client Statement

The resident’s mother said:

“After everything my daughter experienced at Muckamore Abbey Hospital, I expected she would finally receive safe and appropriate care. I was shocked to discover that safeguarding concerns were being raised not only by me, but by staff and other families.

Although I was reassured when the SAI review was announced, that quickly turned to frustration due to delays, lack of transparency, and failure to follow proper procedures.

Had the Trust acted properly in October 2021 I believe my daughter would not have had to endure further neglect. It is a damning reflection on the system that my daughter had to endure further safeguarding issues despite her vulnerability and everything she has been through in her life and at Muckamore, and yet there has still not been a proper review into how this was allowed to happen”.

This case highlights the importance of holding public authorities accountable through judicial review in Northern Ireland, particularly in cases involving:

• Adult safeguarding failures
• Healthcare negligence
• Procedural unfairness
• Delays in public investigations

Phoenix Law Belfast specialises in complex public law and human rights cases, supporting families in challenging unlawful decisions and ensuring accountability across health and social care services.