Sussex Safeguarding Adults Boards

Safeguarding Adult

Review Protocol

This protocol will assist professionals to decide when to refer a case for consideration as a SafeguardingAdult Review, as well as providing guidance on the Safeguarding Adult Review process itself.

Contents Page

  1. Introduction 4
  1. Purpose 4

3. Criteria for a Safeguarding Adult Review 5

4. Procedure for making a referral for a Safeguarding Adult Review 5

5. Procedure for undertaking a Safeguarding Adult Review 6

6. Interface with other proceedings or investigations 6

7. Methodology 8

8. Governance 8

9. Timescales 9

10. Responsibilities to the individual(s) and family or carers 9

11. Responsibilities to staff 10

12. The report 10

13. Media, communication and publication 10

14. Implementation and evaluation 11

15. Review 11

Appendices

APPENDIX 1: Referral Checklist 13

Form A – Referral Form 15

APPENDIX 2: Summary of Involvement 18

APPENDIX 3: SAR Methodology Options 21

APPENDIX 4: Roles when using an IMR approach27

APPENDIX 5: Terms of Reference Template 28

APPENDIX 6: IMR Letter Template 29

APPENDIX 7: IMR Template and chronology 30

APPENDIX 8: IMR Overview Report Template 42

APPENDIX 9: IMR Executive Summary Template 45

APPENDIX 10: Systems Methodology 47

APPENDIX 11: Systems Letter Template52

APPENDIX 12: Letter to family template 54

APPENDIX 13: Guidance for Families on SARs55

APPENDIX 14: SAR flowchart56

  1. Introduction

1.1The Care Act 2014 placed a statutory duty on Safeguarding Adults Boards to undertake Safeguarding Adult Reviews (SARs).

1.2This Safeguarding Adult Review (SAR)protocol has been developed by Brighton and Hove Safeguarding Adults Board, East Sussex Safeguarding Adults Board and West Sussex Safeguarding Adults Board; and is part of the SussexSafeguardingAdult procedures.

1.3The protocol will assist professionals to decide when to refer a case for consideration as a Safeguarding Adult Review, as well as providing guidance on the Safeguarding Adult Review process itself.

  1. Purpose

2.1The purpose of having a Safeguarding Adult Review is not to reinvestigate or toapportion blame, it is to:

  • establish whether there are any lessons to be learnt from thecircumstances of the case, about the way in which local professionals andagencies work together to safeguard adults,
  • review the effectiveness of procedures,
  • inform and improve local inter-agency practice,
  • improve practice by acting on learning, and,
  • highlight good practice.

5

2.2 Safeguarding Adult Reviews are not disciplinary proceedings, and should beconducted in a manner which facilitates learning and appropriate arrangements mustbe made to support staff.

2.3Safeguarding Adult Reviews are not enquiries into why an adult has died (or been significantly injured), or who is culpable. These are matters for criminal courts and coroner’s courts.

  1. Criteria for a Safeguarding Adult Review

3.1A Safeguarding Adult Review (SAR)should always be considered if:

  • an adult has died (including death by suicide), and abuse or neglect isknown or suspected to be a factor in their death;

or

  • an adult has experienced serious abuse or neglect which has resulted in: permanent harm, reduced capacity or quality of life (whether because of physical or psychological effects), orthe individual would have been likely to have died but for an intervention;

and

  • there is concern that partner agencies could have worked more effectively to protect the adult.

3.2Safeguarding Adults Boards (SABs)may also arrange for a SAR in any other situation which involves an adult, in its area, with needs for care and support.

3.3If the SAR criteria are not met but the Board feels there are lessons to be learnt an alternative review maybe undertaken. Please see section 6.

  1. Procedure for making a referral for a Safeguarding Adult Review

4.1The Safeguarding Adults Board is the only body that can undertake a SafeguardingAdult Review.

4.2Any professional can make a referral for a Safeguarding Adult Review.

4.3Staff will usually find it helpful to discuss their concerns with their organisation’s safeguarding lead prior to making a referral. Using the referral checklist (Appendix 1).

4.4Referrals are made via secure email. Seereferral form A.

4.5Discussions regarding theappropriateness of referring a case are welcomed by the SafeguardingAdults Board Manager.

  1. Procedure for undertaking a Safeguarding Adult Review

5.1Once a referral is received, the Chair of the Safeguarding Adult Review subgroup, supported by the Safeguarding Adults Board Manager, will discuss with members of the subgroup to consider whether the criteria are met.

5.2Agencies can be asked for additional information by the Board Manager in order toinform this decision. Please refer to Appendix 2.

5.3The Chair of the Safeguarding Adults Board is responsible for deciding whetherto undertake a review or not, based on the recommendations of the SafeguardingAdult Review subgroup.

5.4The methodology for undertaking a SAR will be discussed and agreed by the subgroup and the Chair of the Safeguarding Adults Board. Please refer to Appendix 3.

5.5The Safeguarding Adults Board Manager or Chair of the SAR subgroupwill inform the referrer in writing of thedecision. If the decision is to undertake a SAR, the Board willmake arrangements to notify the individual, their family or carers (where appropriate), partner agencies of the Board and the Care Quality Commission (regulator of health and social careservices) if registered services are involved.

5.6 When a decision is made to undertake a SAR, a SAR Panel will be convened.

  1. Interface with other proceedings or investigations

6.1It may be necessary to consider whether the case meets the criteria for other multi-agencyreviews.

6.2The Board acknowledges that the following are statutory:

  • Serious Case Reviews concerning children
  • Domestic Homicide Reviews
  • MAPPA Serious Case Reviews
  • Mental Health Homicide Reviews
  • Serious Incident

6.3There may be criminal or coronial investigations running concurrently with the SafeguardingAdult Review. Steps need to be taken to ensure the adult is safe, and any proposals for review must ensure the SAR does not prejudice criminal or judicial proceedings.

6.4In some cases, criminal proceedings may follow the death or serious injury of an adult. The SAR subgroup Chair should discuss how the review process should take account of such proceedings with the relevant criminal justice agencies (such as the police and the CPS) at an early stage. Consideration should be given to, for example, effects on timing, the way in which the review is conducted (including any interviews of relevant personnel), what the potential impact on criminal investigationsis and who should contribute at what stage? Work to understand and learn from the case can often proceed without risk of contamination of witnesses in criminal proceedings.

6.5It may also be necessary to delay the publishing of overview reports until theconclusion of any criminal trial. Individual agencies can however progress withimplementing the learning from the review.

6.6It is also acknowledged that all agencies will have their own internal or statutoryreview procedures to investigate serious incidents. This protocol is not intended toduplicate or replace these and any opportunities to prevent duplication will beencouraged.

6.7In some cases, dependent on the specific issues in the case, internal

investigation reports may provide adequate information to address the terms ofreference; or it may be that additional reports are required to address any outstandingareas. Careful planning and communication is required to make the most effectiveuse of resources and avoid duplication.

6.8Safeguarding Adult Reviews are not part of any disciplinary process. However,should information emerge in the course of the Safeguarding Adult Review that mayindicate that disciplinary action should be taken; the agencies concerned should dealwith such issues in accordance with their own procedures. If disciplinary matters are in progress at the commencement of the SafeguardingAdult Review these should be notified to the Board Manager.

  1. Methodology

7.1Safeguarding Adult Reviews can be conducted in a variety of ways. Traditionalmethods involve analysis of the involvement of agencies, led by an independent overview report author. With this method individual agenciesare asked to review the practice within their organisation through IndividualManagement Reviews (IMR) and Chronologies which then form part of an Overview Report. Please see Appendix 7.

7.2More recently, ‘systems learning’ (i.e.a model introduced by the Social Care Institute for Excellence following the Munro Review of Child Protection published in 2011) has been introduced as an alternative method. This approach sets out to study the whole system and look closely at what influenced professional practice. It does this by taking account of the many factors that interact and influence individualworker’s practice in a more in-depth way. The process seeks to be collaborative with professionals being actively involved in the review from the outset. Please see Appendix 10.

7.3The Safeguarding Adults Board will endorse the approach best suited tothe circumstances of each individual case, and the SARsubgroup will decide on the most appropriate method. Please see Appendix 3 –SAR methodology.

  1. Governance

8.1Safeguarding Adult Reviews are overseen by the Safeguarding Adults

Board, which is a multi-agency partnership with senior manager representation from all the key agencies. The Board isresponsible for ensuring that effective systems are in place for the completion of Safeguarding Adult Reviews,including:

  • decision making in respect ofundertaking reviews,
  • formally accepting reports, and
  • agreeing sign off of the reportfor publication.

Please see Appendix4 and 10.

8.2Responsibility for the management of Safeguarding Adult Reviews is delegated tothe SAR subgroup. This group is responsible for the effectiveness of the SAR Panel to ensure timely completion of reviews. The SAR subgroup will keep the Board updatedand make recommendations as required.

8.3Safeguarding Adult Reviews will be presented to the Board on completion.

8.4Involved organisations will be provided with copies of reports for comments onfactual accuracy prior to the final draft. Where a Safeguarding Adult Review Panel isestablished it will be the role of the Panel to ensure the report is factually accurateand based on the evidence gathered during the process.

8.5All involved agencies will be asked to participate in identifying solutions to any recommendations of the review to support improvements in practice.

8.6Boards and organisations should co-operate across borders, and requests for the provision of information should be responded to as a priority – see ADASS Safeguarding Adults Policy Network Guidance:

  1. Timescales

9.1Safeguarding Adult Reviews must be completed in a timely manner.

9.2Once thedecision to undertake a Safeguarding Adult Review has been made, it is good practice for it to be completed within six months.

9.3It is acknowledged that where there are dual processes or reviews that are complex, these may require more time. Any urgent issues which emerge from the review and need to beconsidered without delay should be brought to the attention of the Board.

  1. Responsibilities to the individual (s) and family or carers

10.1It is important that consideration is given to the best means of notifying the individual(s) (where possible), and their relatives and carers (where appropriate) that a review is being undertaken. Please see Appendix 12.

10.2Individual(s) will be notified that the review will look at records and notes held by public bodies, including adult social care and health providers.

10.3Where appropriate, the Board will make arrangements for the individual(s) and/or their family andcarers to participate inthe Safeguarding Adult Review. Their consent is not required for the review to goahead. Please seeAppendix 13.

10.4Individual(s) and/or their families and carers should be kept updated at key stages of the review and notified of thepublication of the report.

  1. Responsibilities to staff

11.1The staff directly involved in the care and support of individuals subject to aSafeguarding Adult Review should be notified of the decision to undertake a Safeguarding Adult Review, and there is an expectation that support will be provided to them by their agency. The process and their involvement should be fully explained.

11.2At the end of the process staff will be invited to share their experiences and give feedback on the process.

  1. The report

12.1In compiling the SAR report, it should:

  • provide a sound analysis of what happened,
  • containfindings or recommendations of practice value to organisations and professionals, and
  • be written in plain English.

Please see Appendix 8.

12.2Where appropriate, arrangements will be made to share the report and its findings with the individual(s), and / or theirfamily and carers.

12.3The final report will be signed off by the SAB.

  1. Media, communication and publication

13.1 The SAR subgroup Chair, in consultation with the SAB Chair, will consider appropriate publication of the report on a case by case basis. Discussions about publication will be held with the individual(s),their family or carers (where appropriate).

13.2Since Adult Social Care is the lead agency, media and communicationissues will usually be co-ordinated by the council’s Communications Team. This will be done in collaboration with the communications teams of the other agencies involved, alongside agreed representatives of the Board.

13.3All SAR reports will be considered for publication on the website of the relevant Safeguarding Adults Board. In the case of publication, the Chair of the Safeguarding Adults Board will release a statement where appropriate.

  1. Implementation and evaluation

14.1The real value of the completion of a Safeguarding Adult Review is to ensure that the relevant lessons have been learnt and that professional multi-agency safeguarding is improved, in order to prevent the issues in question happening again.

14.2The SAR subgroup will consider the recommendations from the report and agree an action plan (if required).

14.3The SAR subgroup will be responsible for ensuring the implementation of the action plan, monitoring the progress made and making links with relevant subgroups of the Board as required.

14.4 Following the completion of a SAR, learning will be cascaded through single and multi-agency learning and development opportunities and SAB bulletins.

  1. Review

15.1There will be a formal annual review of this protocolto take account of developmentsand new legislative requirements.

APPENDICIES

Please note these are suggested templates

APPENDIX 1: Referrer Checklist and Guidance - for making a Safeguarding Adult

Review referral.

When making a SAR referral you may find the following checklist helpful in discussion with your agency’s Safeguarding Adults Lead:

Question or consideration / Yes/No/ / Comments
Has the adult(s) died?
Has the adult(s) suffered significant harm?
Is there clear evidence of a risk of significant harm to an adult?
Was the harm recognised by agencies or professionals in contact with the adult or perpetrator?
Was information shared with others?
Did agencies or professionals act upon the information appropriately?
Was the adult abused in a care setting?
Did any agency or professional consider their concerns were not taken sufficiently seriously, or acted upon appropriately, by another?
Does the case indicate that there may be failings in one or more aspects of the local operation of formal safeguarding adults’ procedures, which go beyond the handling of this case?
Does the case appear to have implications for a range of agencies and/or professionals?
Does the case suggest that the SAB may need to change its local protocols, procedures; or that protocols and procedures are not adequately being publicised, understood or acted upon?
Are there any exceptional circumstances e.g. good practice learning, significant political or media interest?

Referrer Guidance:

All SAR requests will be assessed by the SAR subgroup in accordance with the Sussex Safeguarding Procedure/Guidance for conducting Safeguarding Adult Reviews.

Please include as much information as possible and answer each question giving details of:

  • the name(s) and date(s) of birth of the victim(s) (if known);
  • name of any service provider involved;
  • local authority involved in the safeguarding adults case;
  • name of the Safeguarding Adults Co-ordinating Manager and/or the Chair of any safeguarding meeting (if known) and
  • details of why, in the referrer’s opinion, the case meets the Safeguarding Adult Review criteria and guidelines contained in paragraph 3 of the protocol, specifically linking the referred to the criteria.

Please note that the report should not exceed 3 sides of A4 paper. If any additional information is required you will be contacted.

Form A

SAR Referral Form

REFERRAL INFORMATION
NAME OF PERSON MAKING THE REFERRAL
NAME OF YOUR AGENCY
YOUR POSITION
YOUR EMAIL ADDRESS
YOUR ADDRESS
YOUR CONTACT NUMBER
DETAILS OF PERSON BEING REFERRED FOR A SAR
NAME OF PERSON BEING REFERRED
DATE OF BIRTH
Next of Kin
DATE OF INCIDENT OR ISSUES
Is the person deceased or alive?
Has the person or family member been informed of the SAR referral?
AGENCIES INVOLVED / KEY CONTACT NAME / CONTACT DETAILS / Has the agency been informed about the SAR referral?
REASON FOR REFERRAL – PLEASE DO NOT EXCEED 3 SIDES OF TEXT
Please refer to the Sussex Safeguarding Adults Policy and Procedure Manuel; and consider if your referral meets the following criteria:
SABs must arrange a SAR when an adult in their area dies as a result of abuse or neglect whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. In the context of SARs, something can be considered serious abuse or neglect where, for example the individual may likely have died had it not been for an intervention or has suffered permanent harm or reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect. SABs are free to arrange for a SAR in any other situations involving an adult in their area with needs for care and support.
The SAB should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults.
SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.
Insert your summary here:
Completed by
Signed
Date
Pl Please submit this form for the attention of: Head of Adult Safeguarding
Tel: 01273 335277
Email:
(NB: Confidential information should be password protected and the password e-mailed separately)
To be completed by Board Manager
Da Date SAR referral was discussed:
fSAR criteria met: / Y / gSAR criteria not met:
Date sent to Independent Chair: / Date Independent
Chair approved
Referral:
Rationale for decision and proposed methodology:
Comments from Independent Chair:

Please note these are suggested templates