Topic outline

  • 1. Introduction

    ‘No Secrets’ (2000) issued by the Department of Health and the Home Office, issued guidance on developing and implementing multi-agency policies and procedure to protect Adults at Risk from abuse. From 1st April 2015, No Secrets was repealed and replaced by the Care Act 2014.

    The document Safeguarding Adults published by the Association of Directors of Social Services (ADSS) October 2005 provides a National Framework of Standards of good practice and outcomes in adult protection work (now referred to as adult safeguarding). Standards 1.22 and 1.23 stipulated that, as good practice, Safeguarding Adults Boards should have a Serious Case Review Protocol in place. These are now called Safeguarding Adult Reviews (SARs), in line with the Care Act 2014 changes.  Sunderland has a  Safeguarding Adult Review Protocol

    Standard 1 of the 'Safeguarding Adults: A National Framework of Standards for good practice and outcomes in adult protection work' recommends that:

    "There is a 'Safeguarding Adults' serious case review protocol. This is agreed, on a multi-agency basis and endorsed by the Coroner's Office, and details the circumstances in which a serious case review will be undertaken. For example: when an adult experiencing abuse or neglect dies, or when there has been a serious incident, or in circumstances involving the abuse or neglect of one or more adults. The links between this protocol and a domestic violence homicide review should be clear" (Safeguarding Adults: A National Framework of Standards for good practice and outcomes in adult protection work, ADSS, 2005).


    ‘There is a clear process for commissioning and carrying out of a Serious Case Review by the partnership'.

    The Care Act 2014 includes a requirement for Local Authorities to hold Safeguarding Adult Reviews in certain circumstances and for partners on the Safeguarding Adults Board to co-operate in the process. Following the implementation of this Act ‘Safeguarding Adult Review’ replaces the term ‘Serious Case Review’.

    When an Adult at Risk dies, and abuse or neglect are known or suspected in the death, local agencies need to consider immediately whether there are any other Adults at Risk at risk of harm who may need safeguarding. Thereafter, agencies need to consider whether there are any lessons to be learned from the circumstances of the case about the ways in which they work together to safeguard adults. Consequently, when an Adult at Risk dies in such circumstances, the Safeguarding Adults Board should always conduct a Safeguarding Adults Review into the involvement of agencies and professionals. Additionally, the Safeguarding Adults Board should also consider whether a Safeguarding Adult Review should be conducted where an Adult at Risk sustains a potentially life-threatening injury or serious or permanent damage to their health or wellbeing.

    • 2. Purpose

      The purpose of having a Safeguarding Adult Review is not to reinvestigate or to apportion blame; any evidence of professional negligence would be dealt with through appropriate routes such as disciplinary procedures in the relevant agency.

      A Safeguarding Adult Review is not an enquiry into how an Adult at Risk has died or who is culpable; that is a matter for coroners and criminal courts respectively to determine as appropriate. Rather it is:

      • To establish whether there are lessons to be learnt from the circumstances of the case, about the way in which local professionals and agencies work together to safeguard adults;
      • To review the effectiveness of policy and procedures (both multi-agency and those of individual organisations);
      • To inform and improve local multi-agency practice;
      • To improve practice by acting on learning (developing best practice);
      • To prepare and commission an Overview Report (depending upon the methodology chosen to support the review process) which brings together and analyses the findings of the various Single-Agency Reports from agencies in order to make recommendations for future action (see point 6 Conduct of the Safeguarding Adult Review below).

      The focus of a Safeguarding Adult Review should be upon the way in which local professionals and agencies work together to safeguard and promote the welfare of Adults at Risk. The focus will be on the outcome of the process; the recommendations / actions and the monitoring and reviewing of the recommendations / actions. It will end sure that all appropriate actions have been taken with a view to learning lessons for the future both locally and nationally. It will also focus on how the learning is shared with appropriate partner agencies.

      There is a legal requirement to carry out Safeguarding Adult Reviews in relation to Safeguarding Adults, where the circumstances meet the Care Act 2014 criteria for these reviews. It is also acknowledged that individual agencies may have their own internal/statutory review procedures to investigate serious incidents. The Safeguarding Adult Review protocol is not intended to duplicate or replace these. Agencies may also have their own mechanisms for reflective practice. In order to conform to the objectives set for the Safeguarding Adults Executive Board, there is an expectation that member agencies will support the Safeguarding Adult Review process as set out in this Protocol and/or other review processes which are initiated within the Learning and Improvement in Practice Framework. Also that agencies will have in-house systems in place, which will identify cases that meet the criteria for a Safeguarding Adult Review, and will refer these to the Safeguarding Adults Executive Board.

      Where there are possible grounds for both a Safeguarding Adult Review and a Domestic Homicide Review then a decision should be made at the outset by the two decision makers as to which process is to lead and who is to Chair with a final joint report being taken to both commissioning bodies.

      • 3. Criteria for a Safeguarding Adult Review

        The Safeguarding Adults Executive Board has the lead responsibility for conducting a Safeguarding Adult Review.

        Section 44 of the Care Act (2014) states:

        A Safeguarding Adults’ Board (SAB) must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if:

        1. There is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult; and
        2. Condition 1 or 2 is met.

        Condition 1 is met if:

        1. The adult has died; and
        2. The SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

        Condition 2 is met if:

        1. The adult is still alive; and
        2. The SAB knows or suspects that the adult has experienced serious abuse or neglect.

        A SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

        Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to:

        1. Identifying the lessons to be learnt from the adult's case; and
        2. Applying those lessons to future cases.

        The following principles should be applied by SABs and their partner organisations to all reviews:

        • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the wellbeing and empowerment of adults, identifying opportunities to draw on what works and promote good practice;
        • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
        • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
        • Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
        • In support of the values of Making Safeguarding Personal (Making Safeguarding Personal: Guide 2014. ADASS, 2014) families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively;
        • If an adult has no appropriate person to support them and has substantial difficulty in being involved in the review process, they must be informed of their right to an independent advocate.

        • 4. Process for Commissioning and Carrying out of a Safeguarding Adult Review

          The Safeguarding Adults Executive Board will be the only body able to commission a Safeguarding Adult Review. The Board will publicise both the process under which applications for reviews may be made and the terms of reference for each Safeguarding Adult Review.

          Any agency may refer a case believed to fit the above criteria. The request should not come directly from an individual worker but will first go through their agency’s appropriate management structure. The request should come via a formal written request from the Safeguarding Adults Lead in the agency to the Chair of the Sunderland Safeguarding Adults Executive Board. Requests must be supported and agreed by the members of the Safeguarding Adults Executive Board.

          Requests will include a brief written outline of the case and the factors and criteria that suggest a Safeguarding Adult Review is needed.

          Once an individual/agency has identified that a Safeguarding Adult Review may be required, the request must be made immediately.

          Information shared by the Coroner may be considered for a Safeguarding Adult Review, or, where the criteria are not met, other form of review in accordance with the Learning and Improvement in Practice Framework.

          In the event of an application being turned down, or an alternative form of review being undertaken, in accordance with the Learning and Improvement in Practice Framework, the Chair of the Safeguarding Adults Executive Board will record the reasons in writing and share with the agency from whom the request originated.

          • 5. Initiating a Safeguarding Adult Review

            The Chair of the Safeguarding Adults’ Board will inform the chair of the Learning and Improvement in Practice (LIIP) sub-committee of all requests.

            The role of the LIIP sub-committee is to consider, in light of the information known by agencies, whether the criteria to conduct a SAR are met, as outlined in Section 2 above.

            Where the criteria to conduct a SAR are not met the LIIP sub-committee will consider whether an alternative means of review should be initiated in accordance with the Learning and Improvement in Practice Framework.

            Once all information is considered, and a decision is agreed, the LIIP sub-committee will inform the Chair of the Safeguarding Adults Board of their decision making and rationale.

            The LIIP sub-committee’s decision will be forwarded to the Chair of the Safeguarding Adults’ Board within one month of a case being referred to them.

            The Chair of the Safeguarding Adults’ Board should immediately inform:

            1. The Care Quality Commission (CQC) of any case that becomes the subject of a Safeguarding Adult Review;
            2. The Safeguarding Adults’ Board of the decision, brief circumstances and scope of the Review.

            If it is agreed that the criteria to undertake a Safeguarding Adult Review have been met a Multi-Agency Adult Review Panel will be set up within one month.

            • The Safeguarding Adults Board will be responsible for the appointment of an Independent Panel Chair, and will ensure they receive adequate support;
            • The Chair of the Panel will be responsible for establishing individual terms of reference and setting time scales for the Review in agreement with the Safeguarding Adults Board. They will also be responsible for ensuring administrative arrangements are completed and that the review process is conducted according to the terms of reference.

            Where appropriate, the Independent Chair will liaise with the Coroner’s Office to and/or Police to ensure that arrangements for undertaking a SAR are acceptable and do not conflict with any other investigative processed being undertaken.

            • The Chair of the Safeguarding Adults Board will write to the Chief Officers of all the agencies involved for nominations to the Adult Review Panel;
            • Membership of the Adult Review Panel will be comprised from appropriate representatives of the agencies involved;
            • Each agency will nominate a representative who has appropriate levels of experience;
            • It is acknowledged that resources are required for undertaking and supporting a SAR. It is the responsibility of the Safeguarding Adults’ Board to ensure adequate resources and funding are in place in order for the SAR process to work effectively, to ensure an Independent Chair can be commissioned for each SAR and that the Chair and panel members receive adequate administrative support and will take a decision on how and from whom this will be provided.

            • 6. Conduct of the Adult Review

              The process of carrying out the Safeguarding Adult Review will be as follows.

              • 6.1 The Initial Meeting

                This will agree:

                • The terms of reference;
                • Methodology to be used for the review;
                • The "evidence" required from each agency/ participant;
                • The role the adult at risk and/or family will have in the SAR;
                • The need for Advocacy Services;
                • The support and other resources needed (any perceived deficits to be referred to the Chair of the Safeguarding Adults Board);
                • The time scales within which the review process should be completed, unless there are good reasons for a longer period being required; for example, because of potential prejudice to related court proceedings;
                • Dates, times and venues of meetings;
                • Media strategy;
                • The nature and extent of legal advice required, in particular, Data Protection, Freedom of information and the Human Rights Act;
                • Procurement of a Safeguarding Adult Review Independent Author.

                Consideration and due regard to family members and carers must be observed at all times in the review process, with consideration given to the involvement of an Independent Mental Capacity Advocate. Decisions about contact and communication with the family should be discussed and agreed at the offset of the process and kept under review throughout the process with the panel establishing a suitable professional who can act as a single point of contact to the family members, carers and individual (where relevant) with regard to their involvement in the SAR process. Involvement of individual(s), family and carers should be carefully and sensitively considered with the professional having full cognisance of criminal proceedings.

                There will, in most cases, also be a need for the preparation and implementation of media and communication strategies in relation to the setting up and findings of an Adult Review. Media interest will be co-ordinated through the Chair of the Safeguarding Adults Board and press statements will be co-ordinated through the Local Authority’s Press Department, which would have the agreement of the Chief Executive.

                Freedom of Information requests, in respect of request of information from Adult Reviews, will be dealt with by the Local Authority through the Chair of the Safeguarding Adults Board to ensure consistent and relevant information sharing.

                • 6.2 Receipt of Evidence

                  This stage of the process is a formal "information sharing" session where agencies will be encouraged to query and comment on the reports presented.

                  Each agency involved will produce a report, depending on the methodology used for the Safeguarding Adult Review, outlining all information provided to the review from that agency. Personnel compiling the report should have the appropriate skills, knowledge and training to produce the report.

                  Any arrangements in place to obtain or secure records through statutory agencies, e.g. the police, the Care Quality Commission, should be used whenever appropriate. Where appropriate, advice will need to be sought to ensure that there is compliance with the Freedom of Information Act (2000) and the Data Protection Act 1998.

                  Circumstances may arise whereby it is appropriate to consult or involve a victim of abuse or a relative. How this is to be approached should be carefully and sensitively considered and have full cognisance of criminal proceedings.

                  • 6.3 Discussion of Evidence/ "Adjudication"

                    This stage is where the assessment of alternative courses of action ('what might have been done differently') takes place. The Review Panel will:

                    • Cross-reference all Single-Agency Reports and reports commissioned from any other source;
                    • Examine and identify relevant action points;
                    • Form a view on practice and procedural issues;
                    • Agree the key points to be included in the Overview Report and the proposals for action.

                    • 6.4 Issues Arising

                      If at any stage whilst undertaking the process as outlined above, information is received which requires notification to a statutory body, e.g. Health and Care Professions Council (HCPC) or Disclosure and Barring Service's Barred List, regarding significant omission by individual(s) or organisations this should be done without delay.

                      The Chair of the Review Panel should report back to the Safeguarding Adults Board and a decision made as to whether the Adult Review process should be suspended pending the outcome of such notification.

                      • 6.5 Parallel Processes

                        Criminal investigations and legal proceedings may run concurrently with the Adult Review. Due regard for any criminal / civil processes should be observed at all times in the Review proceedings.

                        Adult Reviews are not part of any disciplinary process but information that emerges in the course of a Review may indicate that disciplinary action should be taken under established procedures in the agency concerned.

                        Alternatively, disciplinary action may be conducted concurrently and in some situations disciplinary action may need to be taken urgently to safeguard others. This will be a matter for the individual agency concerned.

                        Safeguarding Adults practice or procedural changes may be identified as being necessary at any point in the Review process and may be made immediately if identified as urgent in order to safeguard others.

                        • 6.6 Report Stage

                          The Review Panel will complete the review of Single-Agency Reports and those commissioned from any other source and advise the Chair of the Panel on the production of an Overview Report. The Overview Report brings together information from the Single-Agency Reports, analyses the information and makes recommendations. The Panel Chair will ensure that the Overview Report is written and delivered within agreed timescales.

                          The report will contain an Executive Summary which, subject to legal confirmation, will be made public on the Sunderland Safeguarding Adults Board website.

                          The draft report will be presented to the Chair of the Safeguarding Adults Board for comment before being presented to the full Board for discussion. Upon receipt of the Overview Report the Safeguarding Adults Partnership Board will:

                          1. Clarify to whom the report, any or any part of it, should be made available, including the Care Quality Commission and the means by which this will be done;
                          2. Disseminate report of key findings to interested parties as agreed;
                          3. Agree arrangements to feedback to staff, family members or media as appropriate.

                          • 7. Acting on the Recommendations of the Adult Review

                            On completion, the Overview Report will be presented to the Safeguarding Adults Board, which will:

                            • Ensure contributing agencies are satisfied that their information is fully and fairly represented in the Overview Report;
                            • Ensure that the Overview Report contains an Executive Summary that can be made public;
                            • Translate recommendations from the Overview Report into an Action Plan, which should be endorsed at senior level by each agency.

                            The Action Plan will indicate:

                            • Responsibilities for various actions;
                            • Time-scales for completion of agreed actions;
                            • The intended outcome of the various actions and recommendations;
                            • Mechanisms for monitoring and reviewing intended improvements in practice and/or systems;
                            • To whom the Overview Report or parts of the Overview Report should be made available, and agree the means by which this will be carried out;
                            • The processes for dissemination of the Overview Report and/ or key findings to interested parties, for the receipt of feedback and any debriefing to staff, family members and, where appropriate, the media.

                            • 8. Recommendations

                              Action Plans from Adult Reviews will be monitored and evaluated within the Learning and Improvement in Practice Sub-Committee and Quality Assurance Sub-Committee to the Safeguarding Adults Board. It will ensure that all recommendations are actioned and will request updates from the relevant agencies. The Action Plan will remain on the Sub-Committee’s agenda until such time that all actions have been completed.

                              Regular reports to Safeguarding Adults Board regarding progress and exception reports in line with current reporting procedures.

                              • 9. Annual Report

                                All Adult Reviews conducted within the year will be referenced within the Safeguarding Adults Annual Report along with relevant service improvements.

                                • 10. Other Considerations for an Adult Review

                                  • There will be a need to address the budgetary requirements for undertaking a Adult Review;
                                  • Timescales for the completion of an Adult Review will need to be put in place to ensure that the process takes place within six months. By comparison, a Domestic Homicide Review aims to be completed within three months;
                                  • The right under the Freedom of Information Act to request information held by public authorities, known as the 'right to know', came into force in January 2005;
                                  • There are 'absolute' and 'qualified' exemptions under the Act. Where information falls under 'absolute exemption', the harm to the public interest that would result from its disclosure is already established;
                                  • If a public authority believes that the information is covered by a 'qualified exemption' or 'exception' it must apply 'the public interest test';
                                  • The public interest test favours disclosure where a qualified exemption or an exception applies. In such cases, the information may be withheld only if the public authority considers that the public interest in withholding the information is greater than the public interest in disclosing it.