1. 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
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2. 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 ……….
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3. 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
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4. 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.
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5. 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
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6. 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
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7. 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 ….
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8. 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
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9. 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.]
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10. The IMR Approach is the most common
It allows for:
Completeness
Objectivity
Auditability
Emphasis on learning …..
…..and Accountability
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11. 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….
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12. 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 …..
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13. 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)
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14. 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
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15. 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
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16. 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.
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17. 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
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18. 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)
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19. 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)
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20. 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
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21. 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?
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