H&F Safeguarding Adults Review Policy & Procedure

Context and legal background  

The Care Act 2014 created a legal framework for Adult Safeguarding. Section 44 of the Act requires local safeguarding adult boards (SAB) to arrange a mandatory safeguarding adult review (SAR) when a case involves an adult in its area with needs for care and support (whether the local authority has been meeting any of those needs) if—

• 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
• Condition one or two is met

Condition One 
The adult has died and 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)

Condition Two
The adult is still alive and 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 would have been likely to have died but for an intervention or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect

The Care Act 2014 also enables SABs to carry out discretionary SARs or other learning activity in cases which do not meet the mandatory criteria but where it would be appropriate to promote effective learning and improvement action across safeguarding systems to prevent future deaths or serious harm. 
The review process is underpinned by the six safeguarding principles outlined in the Care Act 2014. These are the basis upon which judgements are made about events and practice. 
 

The Care Act [s44(5)] also requires each member of the SAB to co-operate with the review to assist with identifying the lessons learnt from the case and apply those lessons to future cases.

This policy has been drafted in accordance with the Pan London Safeguarding Adults Review Guidelines.

2.    Purpose of a SAR

The purpose of conducting a safeguarding adult review is to draw out the learning from the circumstances of the case, about the way in which professionals and agencies work together to safeguard the adult at risk. This includes:

• Understanding what happened within a specific period of time
• Understanding why it happened
• Reviewing the effectiveness of multi-agency safeguarding arrangements and procedures
• Informing and improving future practice and partnership working
• Highlighting any good practice identified

Its purpose is not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation such as CQC, the Nursing and Midwifery Council, the Health and Care Professions Council, Social Work England and the General Medical Council.

The H&F SAB has also produced guidance on managing allegations against people in a position of trust where appropriate.

3.    Role of the Safeguarding Adults Board

The H&F SAB is responsible for ensuring that effective systems are in place for the completion of safeguarding adult reviews.

This includes decision making in respect of commissioning reviews, developing the action plan and agreeing sign off of the report for publication. The SAR Quality Markers are used as prompts to support good practice, and the H&F SAB has developed a series of checklists based on these quality markers to support decision making and review of draft reports and recommendations.

Responsibility for the management of safeguarding adult reviews is delegated to the Safeguarding Adults Case Review Group (SACRG), a sub-group of the H&F SAB. This group is responsible for maintaining a co-ordination role throughout the process, including providing quality assurance (See Section 4: Safeguarding Adults Review Process)

It will be the role of the SACRG to review referrals for SARs and ensure the final report is factually accurate and based on the evidence gathered during the process prior to presentation to the H&F SAB for agreement. All SACRG members are expected to contribute to discussions and challenge each other as appropriate within the threshold as a ‘critical friend’.

Following receipt recommendations from the SAR author, the SACRG will help create an action plan and all members of the H&F SAB are responsible for ensuring their actions assigned to their agency are completed. SAB members are also responsible for ensuring the learning from the SAR is embedded in their organisation and constituent agencies. Wherever possible, agencies should make every effort to capture learning points and take internal improvement action while the SAR is in progress, rather than waiting for the SAR report and action plan.  

The SAB will also ensure the key learning is disseminated to all staff and volunteers working in H&F, in order to drive forward improvements and ensure learning is embedded. This may be supported by relevant subgroups who can assist in developing learning resources for dissemination.

In the interest of transparency and disseminating learning, the SAB will seek to publish final reports on the website within the legal parameters about confidentiality, unless there are exceptional circumstances that would prevent this. This could be due to a potential risk to an adult(s) or child(ren) should the SAR report be published, or if it is considered a reputational risk to do so.

The SACRG will support the SAB in fulling its responsibility to include findings from any SAR (and information about any ongoing SARs) in its Annual Report along with the actions it has taken, or intends to take, in relation to those findings.  Where the SAB decides not to implement an action then it must state the reason for that decision in the Annual Report.  

4.    Safeguarding Adults Review Process

4.1 Referrals  

Any agency, professional or individual can bring a case to the attention of the H&F SAB and request a SAR if they believe it to fit the criteria listed above. Requests for a SAR must be made in writing using the SAR referral form.

Where referral is made by an agency or professional, the organisation’s internal governance processes should be followed BEFORE referring to the SACRG, ensuring relevant senior colleagues within the organisation are aware and kept informed of the discussions via the organisation’s representative. Equally, it is important to note that if the nature of the incident triggers a mandatory investigation or review within the organisation concerned, this should take place without delay and in line with the organisation’s internal policy requirements. This policy is not intended to duplicate or replace internal review policies and any opportunities to prevent duplication will be encouraged.

All referrals will be reviewed by the H&F SAB Manager to ensure that they are appropriate and give clear rationale for referral. This may include further discussions with the referrer or gathering clarifying information from partner agencies. Where it is felt that referral is inappropriate this will be discussed with statutory partners and SACRG Co-Chairs, and advice sent to referrer.

A referral to the SAR subgroup should not be used as an escalation process or to defer what should more appropriately be dealt with through complaints processes or via an adult safeguarding enquiry process. All referrals will be evaluated by the SAB  Manager to ensure suitability with a record kept of those cases which are deemed inappropriate and do not proceed for consideration of a SAR. Where a case is deemed inappropriate, referrers will be informed in writing and will be given opportunity to have the case reviewed by another member of the SACRG if they disagree with the decision.

4.2 Decision Making

Following receipt of an appropriate referral, notification will be sent to SACRG Co-Chairs and statutory partners via email to allow for input on decision to present to SACRG. On agreement, members of the SACRG will be sent an information sharing request to provide details of what information their agencies hold of the adult(s).

If the SAB requests relevant information from a body or person in the context of a safeguarding adult review, then Section 45 of the Care Act creates a legal duty for that body or person to share what they know with the SAB. The test is that the information requested by the SAB must be for the purpose of enabling or assisting the Board to perform its functions. Should a body or person fail to comply with an information request, this will be escalated via the H&F SAB Chair and the appropriate senior representative within that body.

Any initial information gathered will be shared with SACRG members before any meeting to discuss the referral and each member will be expected to attend the meeting fully briefed and prepared to enable comprehensive and robust discussions. Agencies who are not usually represented at SACRG but who have contributed information will also be invited to attend and contribute to discussion.  

Each referral will be considered carefully and be measured against the criteria  to determine whether a Safeguarding Adults Review should be commissioned, and if so what type of review to recommend to the H&F SAB. Members will refer to the SAR Quality Markers in making decisions using the guidance templates developed by H&F SAB. The SACRG Co-Chairs will submit their recommendation using the referral and decision-making checklist to the H&F SAB Chair.

Once the decision to commission a review has been made, the aim is to complete the process within six months, unless otherwise agreed by the H&F SAB Chair. It is acknowledged that where a safeguarding adult review is more complex it may require more time. Any urgent issues emerging from a review needing to be considered earlier will be brought to the attention of the H&F SAB Chair.

If a request for a SAR is turned down by the SACRG or the SAB Chair, a notification will be sent to referrers to advise them of the reasons for this. Where the referrer is dissatisfied with this outcome, they should notify the Chair of H&F SAB in writing, who will discuss and review (if necessary) the decision with the referrer.  

4.3 SAR Methodologies

The SACRG will use the information gathered as part of the decision-making process to identify the specific areas of enquiry that the independent reviewer, the SAR panel (and by extension all contributors) should consider and reflect on. This will be incorporated into a Terms of Reference agreed with the SACRG and the SAB Chair, which will also outline chosen methodology, expected timeframes for completion and detail on how the adult and/or the family or representative has chosen to be involved.

The type of review chosen will aim to be a proportionate response to the seriousness of the incident, maximise the possibility of learning, and prevent the likelihood of harm to other people who may find themselves in similar circumstances.

In determining the methodology and key lines of enquiry within a review, the SAR panel should set out within the Terms of Reference prior learning and the existing evidential evidence base for good safeguarding practice. This should reference the impact that academic research, case law and both national and local SARs have had practice improvement.  

It is recognised that there are advantages and disadvantages to different methodologies, and SACRG members should seek to consider flexible approaches to methodology, so as not to be too prescriptive.

4.4 Involvement of staff/volunteers

The SAR needs to look beyond records or written reports and understand the context in which the work was undertaken (Preston-Shoot, 2017). How these impact the situation under review is best understood by attempting to understand the perspectives of practitioners and managers, who are often best placed to identify what could change in safeguarding systems and how barriers to best practice can be overcome.

When a SAR has been agreed, staff and volunteers who were involved in the case should be notified of this decision by their agency, and the nature, scope and timescale of the review (as outlined within the SAR ToR) should be made clear at the earliest possible stage. It should be made clear that the review process can be lengthy.  It is important that all relevant staff and volunteers of agencies are given an opportunity to share their views on the case as appropriate to the review methodology selected.

The death or serious injury of an adult at risk will have an impact on staff and volunteers and needs to be acknowledged by the agency. The impact may be felt beyond the individual staff and volunteers involved, to the team, organisation or workplace. Whilst we hope that all practitioners will feel able to take part collaboratively in the SAR we recognise this can be experienced as stressful. Agencies are responsible for ensuring their own staff and volunteers are provided with a safe environment to discuss their feelings and offered support where needed. This support could also include line managers or supervisors attending SAR learning events or interviews with their staff.

Safeguarding Adults Reviews: Information for professionals 

4.5 Involvement of the adult and/or representatives

Adults and/or families should be invited and supported to contribute to SARs if they wish to do so, in order that an inclusive approach is taken and that their wishes, feelings and needs are placed at the heart of the review.  

The person appointed to lead the review should make contact with the adult(s), their family and/ or representatives early on to explain the process and to establish:  
•    How they would like to be involved – e.g., views contributed via telephone conversation, or interview, or attendance at SAR meetings.  
•    Any support or reasonable adjustments they would need to facilitate their involvement.  
•    Their initial views, wishes, concerns, and any answers/ outcomes they would like to achieve from the SAR process.

The adult or their family/representative should be kept updated at key stages of the review and notified of the publication of the report. The SACRG Chair and the Independent Reviewer will agree who is best placed to contact the person or their family/representative. However, consent is not required for the review to go ahead.

An independent advocate may be arranged to support and represent an adult who is the subject of a SAR if it is judged they would experience substantial difficulty in participating in the review process. This includes a person assessed as having capacity to make decisions about their care and support, where there is no other suitable person to support them.

Safeguarding Adults Reviews: Information for family, friends and carers 

4.6 SAR Authors

The SAR will be completed by a reviewer who is independent of the case under review and of the organisations whose actions are being reviewed. This can include reviewers from other partners of the H&F SAB not operationally involved in the case.

When commissioning an independent reviewer to undertake a SAR, the H&F SAB will give consideration to an individual’s experience and expertise in the areas identified within the SAR Terms of Reference, which may include seeking testimonials from previous commissioners.

To ensure transparency, openness and fairness, an advert will be circulated in SAB networks and the network for independent reviewers. Applications from more than one potential reviewer will then be shared with Independent H&F SAB Chair, SACRG Co-Chairs and representatives from SAB statutory partners.  There should always be flexibility to select an independent reviewer without the necessity of a lengthy selection process.  

It is the H&F SAB’s expectation that independent reviewers will adopt an approach of ‘respectful inquiry’ in order to promote trust and collaboration – this means asking open questions and actively listening to answers, and ensuring participants feel their contribution is valued (Van Quaquebeke, 2018).

The H&F SAB would also seek appointment of independent reviewers who can demonstrate strong leadership, facilitation skills, and good analytical skills.

4.7 SAR Reports and responding to recommendations

When undertaking the safeguarding adult review, the records will be anonymised using pseudonyms. Involved organisations will be provided with copies of reports for comments on factual accuracy prior to final draft.

The SACRG should receive and agree any draft report before it is presented to the SAB so that individuals are satisfied that there is sufficient analysis, scrutiny and evaluation of evidence.  The SACRG will seek to ensure that SAR reports provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence.  The report should be written in plain English and contain findings of practical value to organisations and professionals.

The SACRG will translate learning and recommendations from the SAR report into a proposed SMART multi-agency action plan. This will indicate the actions that are needed, responsibilities for specific actions and timescales as well as the intended outcome i.e. what will change as a result.   The SACRG will also develop mechanisms for monitoring and reviewing intended improvements; some of this work may be delegated to other appropriate subgroups, such as the Quality in Practice subgroup

The action plan will be presented to the H&F SAB as it will need to be endorsed at senior level by each organisation to whom it relates.  Individual agencies may also be asked by the H&F SAB to produce their own internal action plans if required. This may include recommendations to national bodies.  
 

4.8 Publication of reports

The findings of any SAR should be reported within the SAB’s annual report. Whilst there is no legal duty to publish the full report, consideration should be given to the wider public benefit of doing so. It may prove necessary to redact information and, to protect the adult and family members, anonymise personal information.

Given the purpose of a SAR, draft reports are not intended for publication or wide dissemination as they will be subject to consultation with wider partners, the adult and family to ensure factual accuracy and deliverability. As such, once a final report is ratified by the SAB any draft reports may be destroyed.  

Publication of the final report will usually be via SAB website and a copy of the report will be made available to the National Network’s SAR Library. A copy of the Report will be retained by the SAB (or local authority under s43 Care Act) for a minimum of 20 years following the publication of the SAR. This takes into account that the information might be required to protect other adults at risk, need to be accessed by the data subject at a later date or be subject to future investigations, inquiries and litigation.

5.    Interface with other proceedings or investigations

Some SARs may overlap with other statutory review processes such as a Domestic Homicide Review, Mental Health Homicide Review, Learning Disabilities Mortality Reviews (LeDeR) or a Child Safeguarding Practice Review. The chairs of the respective review processes will formally discuss and agree how the interfaces between these should be managed and to dovetail activity as far as possible.

There may be criminal or coronial investigations running concurrently with the SAR. Any proposals for a SAR must ensure that they do not prejudice criminal or judicial proceedings. In cases where criminal proceedings are taking place the SACRG should seek to discuss how the review process should take account of these with the relevant criminal justice agencies (such as the police and the CPS) before planning the SAR. 

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 investigations is 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.

It is essential the SAR reviewer liaises closely with the relevant senior investigating officer from the other agencies concerned to make sure that professionals and members of the public that are likely to be called at a witness trial are not compromised by the activity of the review. It may also be necessary to delay the publishing of reports until the conclusion of any criminal trial. However, individual agencies can progress with implementing the learning from the review.