WHAT CAN WE LEARN FROM COMPLETED SARS? FINDINGS FROM TWO THEMATIC REVIEWS UNDERTAKEN BY MICHAEL PRESTON-SHOOT

Care Act 2014: statutory duty to review serious cases An 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…

SAR Statutory Duty 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 (a)the adult has died, and (b)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).

SAR Statutory Duty or the adult is still alive, and the SAB knows or suspects that the adult has experienced serious abuse or neglect. An 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).

Focus of Studies What learning themes emerge? How does the learning help us understand what goes wrong? What changes are recommended in order to prevent recurrence? Sample 38 SARS 12 organisational abuse 13 self neglect 7 combined involving neglect with self neglect

Direct Practice With the Adult Learning about practice Mental Capacity Risk assessment Lack of persistence in engagement Refusal taken at face value: ‘lifestyle choice’ MSP; Missing or over prioritised Absence of understanding about history / meaning Failure to think family Concerns about service quality

Direct Practice With the Adult Assessments absent or inadequate Failure to recognise and act on persistent and escalating risks Risk Assessments missing, poorly performed or not reviewed Absence of detail about best interest decision making Mental Capacity Unclear focus on individuals wishes, needs and desired outcomes. Focus on autonomy excludes consideration of risk to others and duty of care MSP Lack of curiosity about meaning of behaviour and key features in a biography Understanding and History

Organisational Factors Learning about organisations Absence of supervision and managerial oversight Absence of escalation Workflow practices constrain involvement Records unclear, incomplete or missing Resource challenges: time, staffing, placements Agency culture QA and contract monitoring Failure to track patterns and concerns

Organisational Factors Missing or unclear policies; lack of attention to roll out Safeguarding knowledge and confidence Failure to ensure staff competence for work required Insufficient attention to legal powers and duties

Interagency Cooperation Learning about working together Silo working Failures of communication and information sharing Lack of leadership and coordination Absence of challenge to poor service standards Absence of legal literacy Collective omission of “the mundane and the obvious”

Interagency Cooperation Absence or non-use of multi-agency forum Absence of Escalation Inadequate recognition, referral and response to safeguarding

Conclusions Unique and complex pattern of shortcomings Learning rarely confined to poor practice Weaknesses in all layers of the system Taken together they add up to a ‘fault line’

Next Steps Locally Following related safeguarding adults forum we will Disseminate information via different methods including Chair of the Board newsletters Podcasts Posters Forum engagement

Next Steps TSAB will review completed action plans within agreed timescales to check on how well SAR recommendations have been implemented - ‘so what’s changed in reality’ TSAB is reviewing its governance systems for the commissioning, management and reviewing of safeguarding adult reviews.

Next Steps We are working with regional ADASS to produce consistent guidance on common themes such as Threshold guidance Risk Assessment Self neglect

Safeguarding Contact Points To raise an adult abuse safeguarding referral please contact 01803 219888 or safeguarding.alertstct@nhs.net To make a safeguarding adult review referral contact 01803 219760 or tsdft.torbaysafeguardingadultsboard@nhs.net mark subject as SAR referral Julie Foster – Independent Chair, Torbay Safeguarding Adults Board. Contact via 01803 219760 or tsdft.torbaysafeguardingadultsboard@nhs.net Jon Anthony – Torbay Operational Lead 01803 219831