36 Safeguarding adults reviews

View notes on this clause

(1) An SAB must arrange for there to be a review of any case in which—

(a) an adult in the SAB’s area with needs for care and support (whether or not the local authority was meeting any of those needs) was, or the SAB suspects that the adult was, experiencing abuse or neglect, and
(b) the adult dies or there is reasonable cause for concern about how the SAB, a member of it or some other person involved in the adult’s case acted.

(2) Each member of the SAB must co-operate in and contribute to the carrying out of the review with a view to—

(a) identifying the lessons to be learnt from the adult’s case, and
(b) applying those lessons to future cases.

13 Responses to 36 Safeguarding adults reviews

  1. Hilary Paxton says:

    Am interested to understand the change of terminology here. Why safeguarding adults reviews and not Safeguarding Adults serious case reviews? The Government did not explain this in their response to the Law commission proposals. In this field we all talk of SCRs, and some areas also have other methods of learning lessons, without the expense of an SCR, where it is less serious but lessons would be valuable. Are the Government trying to include the possibility of other types of learning the lessons reviews? Or is it a terminology change by mistake?

    • Edna Fletcher says:

      Adult safeguarding may be considered more a problem than child protection when nearly 2/3 of alerts are unsubstantiated/ undetermined.

      Adult safeguarding decisions may be less than robust. Clearly, also, incapacity and CoP challenges can override decisions made after safeguarding actions have been taken by social workers. E.g. Hillingdon Council/ Mark Neary. There would be lessons to learn not relevant to serious case reviews, in many cases where the wishes of the adult and his her needs have been over ridden through the demonising of the family / parent and fabrications about the safeguarded adult.

  2. Norman Sterling-Baxter says:

    The breadth of the terminology allows the SAB to determine locally what type of review is appropriate – Serious Case Review, lesson learned review, internal management review – dependent on the agencies involved.

    • Auth says:

      Adult safeguarding may be coiednersd more a problem than child protection when nearly 2/3 of alerts are unsubstantiated/ undetermined. Adult safeguarding decisions may be less than robust. Clearly, also, incapacity and CoP challenges can override decisions made after safeguarding actions have been taken by social workers. E.g. Hillingdon Council/ Mark Neary. There would be lessons to learn not relevant to serious case reviews, in many cases where the wishes of the adult and his her needs have been over ridden through the demonising of the family / parent and fabrications about the safeguarded adult.

  3. Liz royle says:

    The term reasonable concern should be expanded – clarified – in order that the SAB only undertakes case reviews where there is there is a high level of concern or significant concerns. Thus lack of clarity could lead to SAB undertaking an increased number of case reviews which would be costly and the case best reviewed using other processes / mechanisms.

    It would be useful to develop further guidence for SABs on case reviews – thresholds and processes with consideration given to the emergence of systems approaches that are being piloted in LSCBs.

  4. Belinda Schwehr says:

    I have had a bitter experience of trying to persuade a council in a safeguarding sage running on for 18 months, that a serious case review was necessary, and was told that it could not happen until the safeguarding process was over; and yet the co-ordinator of the authority in question said that he did not have the resources or the forensic skills to bring it to a conclusion within the foreseeable future. I was never given written reasons for the council’s refusal to engage with the other parties concerned – a PCT, and an independent hospital – over the need for an SCR. So I fear that without an additional duty to give reasons for an opinion that no such investigation is called for, within the parameters of the proposed statutory trigger, this sort of thing will just go on.

    • liz says:

      and this is why additional guidence relating to SCR / case reviews is needed – the situation you describe is lamentable. It also points to the financial issues that are not addressed within this Bill.

  5. Marie Chappell (on behalf of the East Riding of Yorkshire Safeguarding Adults Board) says:

    Introduction.
    The East Riding of Yorkshire Safeguarding Adults Board held a multi agency/multi disciplinary consultation event which also included service user representatives and carers on 26th September 12. The event focussed on those aspects of the Care & Support Bill relating to safeguarding ‘Adults at Risk’ and also took the opportunity to seek views on the new ‘Safeguarding Power’. The below responses reflect the general debate and the main points from the small group work that took place.

    Section 36-Safeguarding Adult Reviews

    There was some confusion in what the legislators are trying to achieve in this section, the dropping of the word ‘serious’ may increase the number of reviews that take place, is that the intention? However the framing of sub-section 36 (1) (b) does not appear to provide the necessary clarity in respect of when a ‘review’ should take place. The use of the term ‘review’, rather than ‘safeguarding review’ or something similar within the wording of the section is confusing as this term alone has a totally different meaning within other areas of care for ‘adults at risk’. Again a significant amount of guidance will be necessary to ensure that this aspect of the legislation is applied with a degree of consistency across the country and as the legislators intend. Lessons must be learnt from the more mature Children’s Serious Case Review process which does not appear to have been effective at applying lessons learnt in one area to other areas of the country.

    Summary of Group Feedback

    • What are they? What are they for? If definition is not clear could end up with high numbers of them.
    • Need clear criteria to enable consistency across areas.
    • Should be clear if they happen, they are about improving practice with some tangible outcomes which can be shared as widely as possible. Not about apportioning blame.
    • Not clear whether this is an extra layer over and above what has already been done.
    • Difficulty with the wording with clause (1)b needs re-wording
    • Are they only to be undertaken when a person has died? Where is the logic? If not needs to be made explicit.
    • Sounds like something less than a SCR but have made this assumption. Is this correct?
    • Why not just share the anonymised reports and lessons learnt reviews and SAB SCR findings and recommendations?
    • Needs to be specifically a Safeguarding review rather than just a review – this means anything.
    • What happens with the learning from Sudden Untoward Incidents within a health setting, where does this report?
    • Who’s going to fund them?
    • Funding can become a barrier to conducting a review.
    • What is the role of the SAB?

  6. Jane Ashman, Independent Chair of Bournemouth & Poole Safeguarding Adults Board says:

    Independent Providers and Voluntary organisations must also co-operate in and contribute to the carrying out of a safeguarding Adults review, as well as members of the SAB.
    This was a notable omission in the Winterbourne View Serious Case Review.

  7. Imogen Parry says:

    I too am puzzled by the change of terminology and wonder why it’s happened. I much prefer the term Serious Case Review (despite the debate about their remit, purpose, quality, thresholds, funding etc etc), as most people, including the public, understand what this means as a result of high profile SCRs, such as Baby P, Winterbourne View etc, and we should avoid introducing yet more jargon. If SARs are to be broadly the same in scope, purpose etc as SCRs, there is no point in another term.

  8. Patricia Kearney, Interim Director of Adult Services, SCIE says:

    Section 36 – SCIE broadly welcomes the making of case reviews mandatory in certain circumstances. Within the policy guidance that will accompany the bill/act, we would suggest noting the recommendation in the revised Working Together that case reviews use a systems methodology in order to maximise learning from safeguarding events. SCIE’s experience in developing Learning Together and other safeguarding resources with the adult care sector is that learning can be achieved from many different safeguarding outcomes, and not just tragic events.

  9. Steve Wellings, Independent Chair, Staffs and Stoke Adult Safeguarding Partnership says:

    We welcome the requirement to review cases where lessons must be learned and also that this can often be done without the formality, time and expense of a serious case review. The threshold for deciding whether the review should be a serious case review should be at the discretion of the SAB.

    We believe that this section should include reference to how the learning from such reviews should be gathered and shared nationally – eg by the DoH.

    We are unclear how these reviews will link to others, eg Domestic Homicide or MAPPA reviews.

  10. Jill Manthorpe says:

    This comment is based on our research funded by the DH on serious case reviews (SCRs) in respect of vulnerable adults. I have read about 50 of these, interviewed about a dozen chairs, and talked to many involved in providing the background support for such reviews and commissioning them. They are characterised by variablity, localism and economy in the main but also sensitivity, proportionality and efforts to make sensible recommendations. Some reveal that co-operation was not always forthcoming and some point to deep failings of standards and a loss of humanity in care. The potential for lessons to be learned is not obvious and follow up processes are not generally explicit.

    Guidance for new SARs will be key. It needs to reflect the growth in other reivew processes (eg domestic homicide) and ways to ensure the co-operation of providers and other commissioners. The DH (and other government departments and regulators) could provide greater confidence that the work on such reviews is taken seriously at national level since many of the SCRs have useful observations on policy, training of professionals (relevant to curricula and regulation) and systems. As others have commented, it is important for learning to be disseminated widely if there are new points or matters need clarifying, and for reports to be available. In my personal view, if the Bill does not provide clarity about when a SAR is to be conducted then this discretion needs to be firmly identified.