Referral form for One Panel

This referral form is to be used when referring a case for consideration by the One Panel for either a statutory review,, i.e. a Safeguarding Adult Review (SAR), Domestic Homicide Review (DHR) or Serious Case Review (SCR) or when a case may not meet the criteria for a statutory review but there is the opportunity to learn lessons.

For the full definition of each statutory review see below:

·  Serious Case Review - Working Together 2015 - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf

·  Safeguarding Adults Review - the Care Act 2014

http://www.legislation.gov.uk/ukpga/2014/23/part/1/crossheading/safeguarding-adults-at-risk-of-abuse-or-neglect/enacted

·  Domestic Homicide Review - https://www.gov.uk/government/publications/revised-statutory-guidance-for-the-conduct-of-domestic-homicide-reviews -

In brief a statutory SAR or SCR is when (1) an adult or child has died or been serious injured and serious abuse or neglect is suspected and (2) there is concern about how agencies have worked together to safeguard the child or adult.

A DHR is when the death of a person over the age of 16 years appears to be the result of violence, abuse, or neglect by a (a) a person whom they were related or had an intimate relationship with or (b) a member of the same household.

When referring a case please firstly contact the advisor to the One Panel, the Head of Strategic Partnerships, on 020 8496 3683 or 07791 322494. Following this please complete the form below and send to:

Secure email:

Tel: 020 8496 2762

1. / Refer
Name: / Role:
Agency: / Tel. number:
Date of notification: / Linked cases if any:
2. / Case outline
Please include
·  details of referral to agency
·  status of adult or child, i.e. subject of a child protection plan, looked after child, subject to a an adult at risk procedure, subject to deprivation of liberty safeguards (DoLS)
·  any other relevant factors
·  brief summary of work undertaken
3. / Subjects details
Last name: / Date of birth:
Forename: / Age (if D.O.B. not known):
Other names used: / Gender:
Ethnicity / Disability
GP / School/college if relevant
Home address:
Name of: Next of kin/nearest relative/relevant persons representative
DOB of above where appropriate
Address of above
Name of other relevant family members e.g. partner, parent, siblings, etc.
Other relevant person’s DOB
Other relevant person’s address
Please add others as required
4. / Reason/s for requesting a discussion (to be completed by the referring agency):
Please ensure you state what is fact and what is opinion, being mindful of judgmental language.
5. / Particular considerations: For example, is there media interest? Are there criminal proceedings? Is the case linked to a complex abuse case?
6. / Decision of the One Panel and action required (to be completed by One Panel) :
Action may include: commissioning statutory, local review, or single agency review; notification to CQC; request Serious Incident or hold establishment concerns review etc.

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