Adult Serious Case Reviews

Jill Manthorpe

What are Adult SCRs?

Definitions vary• Internal – external (even high profile)

• Called many names

• Public – private

• Single or group/institution

• Crossover with complaints/ reviews/management inquiries….

Thresholds for SCRs

• Death – serious harm/concerns of vulnerable adult

• Institutional practices• Problems with agency communications or

relationships• Safeguarding Board concerns• Pressure - championing• Fit with policy & procedures• Panorama + media – something must be

done!

Current policy says (most LAs adopted)

• Permissive (No Secrets)• ADASS (2006) purpose is ‘not to reinvestigate nor to apportion

blame’• To ‘establish whether there are lessons to be learnt from the

circumstances of the case about the way in which local professionals & agencies work together to safeguard vulnerable adults

• & review the effectiveness of procedures (both multi-agency and those of individual organisations)

• & inform and improve local inter-agency practice• & improve practice by acting on learning (developing best practice)• & prepare or commission an overview report which brings together

and analyses the findings of the various reports from agencies in order to make recommendations for future action’

Chairs told us

• Get admin support (and support for them)

• Know how to unlock doors

• Build up experience• Keep process going• Not always in control• Limited call back to

review• Independent chair

not always necessary

• Independence has its uses (& costs)

• Little knowledge of learning – under-developed ways of monitoring recommendations

• Delays frustrating but explicable

Looking at 22

• Communication problems 17

• No lead agency 5

• Training needed 13

• Whistle-blowing problems 3

discretion

• No set process – so decide !

• Identify resources

• Agree purpose & terms of reference

• Present chronology & facts, missed opportunities, think system

• Ascertain co-operation

• Establish ways to monitor & learn

Thinking systems (Munro)

• Recognise staff are neither autonomous or puppet

• Why did poor practice happen?

• Improve learning

• Think sailing boat not train..

Example 1: content

• ‘The report has four main elements after the introductory sections: good practice that was noted, lessons that have been learnt, changes in policy and practice that have been made since the events, and recommendations for action to improve adult safeguarding further’. (+Action Plan 37pp)

Somerset Safeguarding Adults Board

Serious Case Review concerning

Parkfields Care Home Overview report by

Margaret Sheather, Independent chair of

the Review May 2011

Example 2

Executive Summary of the Serious Case Review in respect of Adult A DOB: 03/07/1945 DOD: 10/03/2010

Author: Margaret WilliamsApx 3: Key people/organisations involved with Adult A page61/65 (excluded neighbours)

Example 3: terms of referenceTerms of reference for the SCR as

established by the Board. • To establish the circumstances

and events surrounding the death: • to examine the management of his

care by individual agencies; • to review the effectiveness of both

multi agency & individual policies and procedures and operational methods & examine the probability of whether any changes would have changed the outcome;

• to inform and improve local inter-agency practice;

• to make recommendations for future practice and to provide explanation and insight for Bill’s relatives

Serious Case Review Executive Summary

“Bill” The Cumbria Safeguarding Adults Board wish to express sincere condolences to Bill’s family. 2009

Logos of County Council, NHS & Police

Example 4

• What next

• London Borough of Merton illustrates keeping on the books approach

‘Recommendations

• The SGAB will ensure that all recommendations are actioned and will request updates from agencies

• The action plan will remain on the SGAB Agenda until such time that all recommendations have been implemented’

Fear of SCR

‘Following the Serious Case Review, ensure a more systematic approach to reviews in the learning disability service, particularly emphasising quality and outcomes.’

Extract from CSCI report to a Local Authority 2007 - feeling that they were ‘hung out to dry’ by making SCR public.

Legal arenas

• ‘In contrast to child care law, adult social care…has developed piecemeal…it remains a confusing patchwork of conflicting statutes…it is characterised by the sheer volume of legislation with much overlap & duplication. It is noted for its ‘baffling and tortuous complexity ..’

• Re A – per Munby J

Legal/Practice Terms

‘No Secrets’ DH 2000 (England & Wales)• ‘In the absence of explicit, comprehensive legislation on

adult protection, DH guidance instead defines vulnerable adults, characterises different forms of abuse and sets out a framework..’ (Mandelstam, ‘Safeguarding Adults and the law’ see SCIE 2011)

• Defining a ‘vulnerable adult’A person ‘who is or may be in need of community care services by

reason of mental or other disability, age or illness; and who is or maybe unable to take care of him-or herself, or unable to protect him-or herself against significant harm or exploitation’ (DH 2000) – but contentious, also described as adult in vulnerable situations or adult at risk…

Case Law• Emphasis on mental capacity at

the centre of decisions Justice Hedley: Re Z (Local Authority: Duty (2004) EWHC 2817 (Fam).

• Social care and health services are there to support not to control – seek authority from the court. Justice Munby -A & C [2010] EWHC 978 (Fam)

• Person’s rights to live with risk ‘What good is making someone safer if it merely makes them miserable?’ Justice Munby MM (An Adult) (2007) EWHC 2003 (Fam), (2009)

• Recognise undue influence and coercion affecting capacity – role is to intervene to reduce the levels of coercion Re SA (2005) EWHC 2942 (Fam)(Case related to forced marriage) – Justice Munby (JE 2009 unreported)  

Existing Legislation

• Human Rights Act 1998• Mental Capacity Act 2005

amended 2007 (DoLS)• NHS & Community Care Act

1990• Health and Social Care Act

2008 – regulation; direct payments

• Equalities Act 2010 • Domestic Violence Crimes and

Victims Act 2004 • SVG Act (vetting & barring)• ……… and the rest!Law Commission Review April

2011

future

• Thinking about:

– Statutory Safeguarding Boards (decided)– Enhanced duty of cooperation– Duty to investigate/ make enquiries– And more..

Thank you

P.S. Please send us any SCRs you think we have missed !

Contact detailse-mail: jill.manthorpe@kcl.ac.uk