1. Findings and lessons learned from Stockport’s SAR Lee Woolfe Safeguarding Adults Board Business Manager

2. What we will talk about What is a Safeguarding Adult Review (SAR)?
The purpose of the SAR
Decision process for a SAR
SAR 1 / Mrs Rogers
Learning points

3. What is a Safeguarding Adult Review (SAR)
A Safeguarding Adult Review (SAR) is a multi-agency learning process that considers:
Why and how serious abuse or neglect happened to an adult and what could have been done to prevent it happening
Could partners work together differently to protect the adult and prevent the abuse that lead to the death or serious harm of an adult with care and support needs
Safeguarding Adult Reviews are a statutory requirement (Section 44, the Care Act 2014)
Safeguarding adult Reviews are about learning together and improving how adults are protected from abuse of all kinds.

4. SAR criteria
An adult at risk dies (including death by suicide) and abuse or neglect is known or suspected
An adult has sustained a potentially life threatening injury through abuse, neglect, serious sexual abuse or sustained serious and permanent impairment of health
Where procedures may have failed in which local professionals and/or services worked together to safeguard adults at risk.
Systematic abuse within an institution
Where circumstances give rise to serious public concern or adverse media interest in relation to an adult/adults at risk.

5. Purpose of a SAR Establish what lessons are to be learned
Identify clearly what those lessons are both within and between agencies
Apply those lessons to service responses including changes to policies and procedures as appropriate
Prevent and improve practice for all Stockport residents and their children through improved intra and inter-agency working

6. Decision to conduct a SAR
SAR panel will meet on receipt of a SAR referral.
The panel will evaluate information and decide whether a SAR is required, and if so a recommendation will be given to the Chair.
The decision on whether to hold a SAR will be taken by the Chair of the SAB.
Appointment of Independent reviewer
The SAR reports should provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence

7. SAR Panel Membership Local Authority (SMBC)
Greater Manchester Police (GMP)
Clinical Commissioning Group
NHS Foundation Trust
Pennine Care NHS FT
Any other agency who may have had involvement with the victim, perpetrator or their families

8. History Mrs Rogers was 82 years of age at the time of her death
She was one of four children who was born, brought up and educated in Stockport
She married at eighteen years of age and had four children. Mrs Rogers’ husband died in 1997 and until her fall she lived alone in a ground floor maisonette with support by her family.
Mrs Rogers was admitted to Hospital having fallen at home.
Mrs Rogers was diagnosed with a fractured pelvis and discharged home the same day.

9. Agencies involved
At the time of Mrs Rogers death she was in contact with and/or known to a number of local services in Stockport.
These were:
Greater Manchester Police
Stockport Adult Social Care
Stockport NHS Foundation Trust [Stepping Hill Hospital]
The care home
Stockport Clinical Commissioning Group
Northwest Ambulance Service (NWAS)

10. Presenting issues & vulnerabilities
Mrs Rogers was unable to cope at home.
Mrs Rogers was provided with two morning calls from carers.
Increased support was identified from a further SW assessment - A 4 visit package could not be provided
Subsequently, Mrs Rogers was admitted to a Rapid Response bed at a care home.
The hub bed scheme was designed to prevent admissions to hospital and to enable people to return to their homes when able.
Mrs Rogers accepted she needed short term residential care to help her recovery.
The move to the care home was also supported by her family who felt she need rehabilitation before returning home

11. Presenting issues & vulnerabilities
Whilst at the home, during the next twelve days Mrs Rogers’ health deteriorated.
Mrs Rogers was taken by ambulance from the care home to Stepping Hill Hospital where she died the same day.
The cause of death:
1a) Peritonitis – which is inflammation of the peritoneum, a thin layer of tissue that lines the inside of the abdomen. It is caused by an infection, which can rapidly spread around the body.
1b) Perforated sigmoid colon diverticulitis

12. Safeguarding concerns
Families concerns:
The family shared concerns at the care home that Mrs Rogers health had deteriorated. The family felt their concerns were ignored.
The ambulance was not recognised until it was too late.
The family said they found Mrs Rogers in her own faeces.
The family reported no rehabilitation had been undertaken during her residency at the care home.
The family said Mrs Rogers had requested gender specific support for but after two days male staff were present.
The family felt there was no dignity shown to Mrs Rogers, or her care.

13. Findings from the review
Prior to Mrs Rogers’ fall she was coping relatively well with good support from her family but unbeknown to the family, she was struggling to undertake all her daily activities.
A 4 visit package couldn’t be provided, which led to an emergency placement.
There was no evidence to that Mrs Rogers had mental capacity to make decisions about her care and accommodation.
Timely assessments of equipment needs - should have been done before the weekend.
The SAR panel thought that the decision to approve a hub bed for Mrs Rogers was a practical and defensible solution to a difficult problem.

14. Findings from the review
The lack of companies offering care provision.
Timely Admissions to a care home are normally planned twenty four to thirty six hours in advance. Planning includes visiting the client, obtaining medical history from the GP.
In this case the care home had approximately seven hours to prepare.
Had the admission been from a hospital the person would have arrived with a discharge letter setting out the medical history, including current medication, relevant to the person’s care.
The Panel noted that, but felt that as hub beds are not planned admissions there should have been a process for dealing with short notice admissions.

15. Learning points SAR process
Timeliness of assessments and providing of adaptive equipment.
Care homes have an emergency admissions procedure.
Access to GP medical information as soon as possible.
Good effective record keeping.
Care Planning “term family support”
Dignity In Care
Medication Policy to be reviewed.
Review Pre Placement Agreement in accordance with Section 45 Care Act

16. Next steps
Action plan that will provide an overview of actions identified from the SAR.
The Quality Assurance Subgroup will oversee and moderate audits, any findings will be circulated to professionals across the partnership.
Review of the prescription model for access to simple equipment - currently prescriptions can be redeemed Monday – Saturday mornings at a retailer of clients own choice.
Complex equipment is available 365 days, 24/7 with a four hour response period if required.
ASC have established a joint quality improvement team to go in to homes and work with providers where there are concerns about quality or safety.
A workshop to be delivered on barriers or issues to prescribed medicines.
Pre –placement agreement has been reviewed to make reference to the use of agency workers and their contribution to any safeguarding investigation, or SAR.

17. How you can make a difference
Take some time to think about what these key messages mean for your practice.
Ask yourself:
Can I make changes to my own practice?
Do I need to seek further support, supervision or training?
Is there anything in my organisation that needs to change so that it can support best practice?
Display 7 minute briefing papers within the workplace

18. Thankyou & Questions
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