1. Learning Lessons from Safeguarding Adult Reviews (SARs)
MQNF 1st March 2017
Helen Jones 
Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board Manager
Steve Dale
Adult Safeguarding Team Leader, Staffordshire County Council
Liz Osburn
Training Officer, Adult Safeguarding

2. This Briefing will Consider:
When the Safeguarding Adults Board will undertake a SAR and its purpose
Failings and why things go wrong
The process for referral for SAR
Opportunity to question at end
What we won’t be talking about -procedure

3. In April 2015 the requirement to undertake SARs became statutory through the Care Act 2014, Section 44
Safeguarding Adult Review 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) either of the following conditions are met

4. 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)
a) The adult is still alive, and
b) The SAB knows or suspects that the adult has experienced serious abuse or neglect

5. “The overriding reasons for holding a review …
“The overriding reasons for holding a review ….to learn from past experience, improve future practice and multi‐agency working. It is not the role of Safeguarding Adult Reviews to apportion blame ‐ that is for the courts or other arenas.’’
Inform of other processes:
DHR
Inquests
Criminal investigation
Disciplinary
HSE
Regulatory Processes SI
Professional Body –NMC,GMC, HCPC
Etc.
Flexibility within the legislation to be proportionate with the SAR – depth, intensity , time, cost,
‘Safeguarding Adults:
Advice and Guidance to Directors of Adult Social Services’ (March 2013)

6. The Purpose of the SAR Establish the facts
Establish whether there are lessons to be learnt
Review the effectiveness of procedures
Inform and improve local inter-agency practice and commissioning arrangements
Improve practice
Highlight good practice
Provide an overview report
After this – production of development plan

7. Safeguarding Adult Reviews in Staffordshire
Case examples

8. 23 year old woman ate herself to death due to rare disorder
Woman eats herself to death after care home removes fridge locks
23 year old woman ate herself to death due to rare disorder
23 year old died from heart failure after putting on 7st in nine months.
She had been living in care home in Staffordshire
Kirsty Derry – see case synopsis in file
Others ongoing …ECM
A 23-year-old woman from the United Kingdom……

9. Themes identified….
3 areas

10. Knowledge Understanding of service user needs
Roles and responsibilities –yours and others’
Legislation –duties and powers
Domestic Abuse
Procedures
Understanding of thresholds
Specialist needs (KCD)
What you should be doing/What can you expect from others –do you know how to refer to others
What should the LA be doing ( duties under Care Act) , MCA and MHA

11. Behaviours Compliance Lack of curiosity Insular approach
Poor communication
Poor risk assessment
Lack of supervision
Lack of challenge
Lack of personalisation

12. Systems Institutionalised practice Number of structures
Complex structures
Learning/development opportunities
Escalation processes

13. Notable in Staffordshire and Stoke Reviews……
Importance of whole family assessment
Intergenerational Abuse
Issues identified around Inter departmental communication
Food/eating and associated risks a common theme
Lack of availability of data in relation to domestic abuse and those with care and support needs
Total SAR/DHR ( ? Over what period of time)
ECM
KD –learning review
MCM
HT – DH learning review
SJE
The need for professional curiosity and move away from ‘tick box’ culture
Lack of application of the Mental Capacity Act

14. The Referral Process

15. Your Questions