1. Adult Serious Case Reviews
Jill Manthorpe

2. What are Adult SCRs? Definitions vary
Internal – external (even high profile)
Called many names
Public – private
Single or group/institution
Crossover with complaints/ reviews/management inquiries….

3. Thresholds for SCRs Death – serious harm/concerns of vulnerable adult
Institutional practices
Problems with agency communications or relationships
Safeguarding Board concerns
Pressure - championing
Fit with policy & procedures
Panorama + media – something must be done!

4. Current policy says (most LAs adopted)
Permissive (No Secrets)
ADASS (2006) purpose is ‘not to reinvestigate nor to apportion blame’
To ‘establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals & agencies work together to safeguard vulnerable adults
& review the effectiveness of procedures (both multi-agency and those of individual organisations)
& inform and improve local inter-agency practice
& improve practice by acting on learning (developing best practice)
& prepare or commission an overview report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action’

5. Chairs told us Get admin support (and support for them)
Know how to unlock doors
Build up experience
Keep process going
Not always in control
Limited call back to review
Independent chair not always necessary
Independence has its uses (& costs)
Little knowledge of learning – under-developed ways of monitoring recommendations
Delays frustrating but explicable

6. Looking at 22 Communication problems 17 No lead agency 5
Training needed
Whistle-blowing problems 3

7. discretion No set process – so decide ! Identify resources
Agree purpose & terms of reference
Present chronology & facts, missed opportunities, think system
Ascertain co-operation
Establish ways to monitor & learn

8. Thinking systems (Munro)
Recognise staff are neither autonomous or puppet
Why did poor practice happen?
Improve learning
Think sailing boat not train..

9. Example 1: content
‘The report has four main elements after the introductory sections: good practice that was noted, lessons that have been learnt, changes in policy and practice that have been made since the events, and recommendations for action to improve adult safeguarding further’. (+Action Plan 37pp)
Somerset Safeguarding Adults Board
Serious Case Review
concerning
Parkfields Care Home
Overview report by Margaret Sheather, Independent chair of the Review
May 2011

10. Example 2 Executive Summary of the Serious Case Review in respect of
Adult A
DOB: 03/07/1945
DOD: 10/03/2010
Author: Margaret Williams
Apx 3: Key people/organisations involved with Adult A page61/65 (excluded neighbours)

11. Example 3: terms of reference
Terms of reference for the SCR as established by the Board.
To establish the circumstances and events surrounding the death:
to examine the management of his care by individual agencies;
to review the effectiveness of both multi agency & individual policies and procedures and operational methods & examine the probability of whether any changes would have changed the outcome;
to inform and improve local inter-agency practice;
to make recommendations for future practice and to provide explanation and insight for Bill’s relatives
Serious Case Review
Executive Summary
“Bill”
The Cumbria Safeguarding Adults Board wish to express sincere condolences to Bill’s family.
2009
Logos of County Council, NHS & Police

12. Example 4
What next
London Borough of Merton illustrates keeping on the books approach
‘Recommendations
The SGAB will ensure that all recommendations are actioned and will request updates from agencies
The action plan will remain on the SGAB Agenda until such time that all recommendations have been implemented’

13. Fear of SCR
‘Following the Serious Case Review, ensure a more systematic approach to reviews in the learning disability service, particularly emphasising quality and outcomes.’
Extract from CSCI report to a Local Authority feeling that they were ‘hung out to dry’ by making SCR public.

14. Legislation and case law No Secrets Consultation
Government
Policy
Legislation and case law
No Secrets Consultation
Inquests, Inquiries and research

15. Legal arenas
‘In contrast to child care law, adult social care…has developed piecemeal…it remains a confusing patchwork of conflicting statutes…it is characterised by the sheer volume of legislation with much overlap & duplication. It is noted for its ‘baffling and tortuous complexity ..’
Re A – per Munby J

16. Legal/Practice Terms ‘No Secrets’ DH 2000 (England & Wales)
‘In the absence of explicit, comprehensive legislation on adult protection, DH guidance instead defines vulnerable adults, characterises different forms of abuse and sets out a framework..’ (Mandelstam, ‘Safeguarding Adults and the law’ see SCIE 2011)
Defining a ‘vulnerable adult’
A person ‘who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or maybe unable to take care of him-or herself, or unable to protect him-or herself against significant harm or exploitation’ (DH 2000) – but contentious, also described as adult in vulnerable situations or adult at risk…

17. Case Law
Emphasis on mental capacity at the centre of decisions Justice Hedley: Re Z (Local Authority: Duty (2004) EWHC 2817 (Fam).
Social care and health services are there to support not to control – seek authority from the court. Justice Munby -A & C [2010] EWHC 978 (Fam)
Person’s rights to live with risk ‘What good is making someone safer if it merely makes them miserable?’ Justice Munby MM (An Adult) (2007) EWHC 2003 (Fam), (2009)
Recognise undue influence and coercion affecting capacity – role is to intervene to reduce the levels of coercion Re SA (2005) EWHC 2942 (Fam)(Case related to forced marriage) – Justice Munby
(JE 2009 unreported)  

18. Existing Legislation Human Rights Act 1998
Mental Capacity Act 2005 amended 2007 (DoLS)
NHS & Community Care Act 1990
Health and Social Care Act 2008 – regulation; direct payments
Equalities Act 2010 
Domestic Violence Crimes and Victims Act 2004
SVG Act (vetting & barring)
……… and the rest!
Law Commission Review April 2011

19. future Thinking about: Statutory Safeguarding Boards (decided)
Enhanced duty of cooperation
Duty to investigate/ make enquiries
And more..

20. Thank you P.S. Please send us any SCRs you think we have missed !
Contact details