Robert Lake Independent Chair of three LSAB’s and SAR Author Birmingham Safeguarding Adults Board Safeguarding Adult Reviews Learning Event 28th September 2018 Robert Lake Independent Chair of three LSAB’s and SAR Author Because Safeguarding is everybody’s business

The SAR Legal Framework (1) Section 44 of The Care Act (in force April 2015) states: A Safeguarding Adult 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:  (a) 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 (b) condition 1 or 2 is met.  Continued ………. Because Safeguarding is everybody’s business

The SAR Legal Framework (2) (ii) Condition 1 is met if: (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). (iii) Condition 2 is met if: the adult has not died but the SAB knows or suspects that the adult has experienced serious abuse or neglect. NB: A SAR should be completed within 6 months of initiation Because Safeguarding is everybody’s business

Safeguarding Enquiries (Section 42 of The Care Act) are not SAR’s Section 42 of The Act applies where a local authority has reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there) who becomes known to them: (a)has needs for care and support (whether or not the authority is meeting any of those needs), (b)is experiencing, or is at risk of, abuse or neglect, and (c)as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it. Because Safeguarding is everybody’s business

The Purpose of a Section 42 Safeguarding Enquiry establish the facts ascertain the adult’s views and wishes (appoint an advocate, if necessary) assess the needs of the adult for protection, support and redress and how they might be met protect from the abuse and neglect, in accordance with the wishes of the adult; make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect enable the adult to achieve resolution and recovery Because Safeguarding is everybody’s business

The Purpose of a SAR To promote effective learning and improvement action to prevent future deaths or serious harm occurring again To gain insights into the way organisations work together to prevent and reduce abuse and neglect of adults To explore examples of good practice where this is likely to identify lessons which can be applied to future cases Not to (re)investigate or to apportion blame Because Safeguarding is everybody’s business

Principles Underpinning a SAR (1) 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 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 Continued …. Because Safeguarding is everybody’s business

Principles Underpinning a SAR (2) 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 Families, or, if still alive, the subject of the review, 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 Because Safeguarding is everybody’s business

SAR Methodologies Include … Traditional Review by Individual Management Report (IMR) Action Learning/Practitioners’ Event (can be combined with an IMR approach) Peer review Significant Event/Serious Incident Analysis/Root Cause Analysis Multi agency combined chronology – may be used to support all the above. [Where the Safeguarding Adults Review criteria are not met the following may be considered: Discretionary Review, Single agency review, Case file audit, No further action.] Because Safeguarding is everybody’s business

The IMR Approach is the most common It allows for: Completeness Objectivity Auditability Emphasis on learning ….. …..and Accountability Because Safeguarding is everybody’s business

The IMR Process (1) Continued…. The IMR author is drawn from the agency concerned but has not been directly involved in the case. Good practice dictates that training should be provided. The IMR Author should: have access to supervision and have had relevant training or experience to support their role as the IMR author be able to gather and analyse information, be able to clearly describe what happened, commenting on the quality of practice Continued…. Because Safeguarding is everybody’s business

The IMR Process (2) The IMR Author should: be able to provide explanations for why something happened (if not, say why not) be able to clearly show how the conclusions relate to the individual case as well as the wider safeguarding practice within the organisation List the sources of information that have been used to compile the IMR ….. Because Safeguarding is everybody’s business

The IMR Process (3) ……which might include paper records, IT systems searched, computer records, supervision notes etc. The IMR author should also include details of staff that have been interviewed as part of this review, or if not why not and say if files could not be found and why. The Report must be countersigned: the IMR must be quality assured and signed off by a senior manager (including the action plan) Because Safeguarding is everybody’s business

Typical Headings for an IMR’s Introduction: Who the author is, what the agency is. The family (use a genogram if it helps) A chronology of events (pre formatted spreadsheet). Analysis of Events – with evidence Conclusions Recommendations and Actions Feedback - How the organisation will learn the lessons Because Safeguarding is everybody’s business

IMR Principles Throughout the IMR, the author should; Challenge her/his own organisation Identify what happened but also include why that happened and what it was that led to the decisions made at the time what were the underlying causes identify learning, necessary recommendations and actions Because Safeguarding is everybody’s business

Hindsight and Bias Actions that should have been taken in the time leading up to an incident can seem obvious because all the facts become clear after the event This tends towards a focus upon blaming staff and professionals closest in time to the incident This can be reduced by using a method of analysis which examines how things were and perceived to be AT THE TIME, why decisions were made and actions taken AT THE TIME. Because Safeguarding is everybody’s business

IMR Authors (1) The IMR Author should: have access to supervision and have had relevant training or experience to support their role as the IMR author be able to gather and analyse information, be able to clearly describe what happened, commenting on the quality of practice Because Safeguarding is everybody’s business

IMR Author (2) The IMR Author should: be able to provide explanations for why something happened (if not, say why not) be able to clearly show how the conclusions relate to the individual case as well as the wider safeguarding practice within the organisation List the sources of information that have been used to compile the IMR …………(continued) Because Safeguarding is everybody’s business

IMR Author (3) ……which might include paper records, IT systems searched, computer records, supervision notes etc. The IMR author should also include details of staff that have been interviewed as part of this review, or if not why not. Please say if files could not be found and why. The Report must be countersigned: the IMR must be quality assured and signed off by a senior manager (including the action plan) Because Safeguarding is everybody’s business

Learning/Practitioner Events The purpose is to understand how partner agencies, individually and collectively, could have worked more effectively to protect the person who has come to harm and to learn/agree how practice can be improved. The Ground Rules are: Confidentiality – existing local Inter-Agency Information Sharing Protocols apply Respect Courtesy Honesty Being open to challenge and to learning Because Safeguarding is everybody’s business

Please Remember…. THANK YOU Any Questions? Whatever the methodology adopted for the SAR, it is not about apportioning blame. It is about promoting effective learning and improvement action to prevent future deaths or serious harm occurring again. THANK YOU Any Questions? Because Safeguarding is everybody’s business