Implementing the Significant Incident Learning Process (SILP) Heather Pick Assistant Director Personal Care and Support Leicestershire County Council Helen Pearson Board Officer Leicestershire and Rutland Safeguarding Adults and Children Board

Pilot Project Background East Midlands Joint Improvement Partnership Safeguarding and Dignity Board reviewed Serious Case Review function and process :  Concerns that SCR’s are not always used effectively  No standardised practice/lack of consistency  Time consuming and resource heavy  Quality of IMRs vary  Lessons learnt not always disseminated in a timely fashion  Much of the process can be remote from frontline practice, lessons get lost

Commissioning Tools and Templates Quality Assurance Framework for Benchmarking Standards in the Commissioning and Delivery of the East Midlands Safeguarding Board for conducting SCR’s and SILP’s in the region PROJECT OUTCOME 1

Project Outcome 2 SILP Pilot Process  Facilitate a ‘live’ SILP process  Evaluation of process and learning outcomes  Inform on any required changes to the process  Cost analysis  Lessons for all on a new process

SILP Criteria  1. Where an adult who may have been in need of safeguarding dies or experiences serious harm where this is not due to direct abuse but there is evidence of self- neglect and/or refusal of service AND there may be concerns about their capacity to self- care and understand the consequences of not doing so.  2. Multiple incidents or concerns with increasing frequency and severity within an institutional setting or involving the same provider agency.  3. Serious harm and/or abuse was likely to occur but has been prevented by good practice.  4. Where there are seen to be high levels of public or media interest in an incident

Aims of the SILP  Learn and own lessons  Openness and critical analysis  Individual and organisational practice  Why decisions were made and actions taken/not taken.  Address changes to practice  Consider how changes will happen  SMART recommendations

What SILP is not……  SILPs are not inquiries into how a vulnerable adult died or was harmed or who is culpable - that is a matter for Coroners and criminal courts  SILPS are not a part of any disciplinary enquiry or process

Managing the SILP process  No legislative framework  No statutory timescales  Shared Learning Experience  New experience for all services

SILP Process SCR Subgroup – recommend SILP Chronology/ summary report writer and front line staff identified Briefing session – TOR and Hopes and fears. SILP Learning EventReport/LessonsFeedback Event /Action Plan

SILP CASE Background  Two Learning Disabled adult males  Sexual assault by one against another in the toilet.  College setting – Adult Education class  Perpetrator supported by PA employed by parent.

Those involved  Police  MAPPA  Adult Social Care – Learning Disability Team  Community Opportunities  Health Learning Disability Nursing Services  Adult Learning

Learning from SILP  Adult Ed -changes to course enrolment forms  Community Ops Project – Poster for notice board  Training for Police re Learning Disabled adults as alleged perpetrators  Recording of sexually inappropriate behaviour ( clarity and transition child-adult)  Adult Social Care – responsibility for sharing information to PA’s  Clarified issue of access to Psychological service during investigation process

Learning – Pilot and subsequent SILP Positive process for those involved if:  Address hopes and fears  Timing of SILP ( other process)  Getting the right people involved  Ensuring all contributions are obtained and valued at events  Consider how to involve subject/family  Combined Chronology ( time line /key events)  Agreeing lessons learned  Confidentiality  Cost  Skilled Facilitators