Safeguarding Adults Review Policy 2021

The purpose of holding a Safeguarding Adult Review is not to reinvestigate or to apportion blame; it is concerned with preventing future deaths/serious abuse, harm or neglect occurring again.

Safeguarding Adult Reviews should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented serious abuse, harm, neglect or death.

This is so that lessons can be learned from the case and applied in future to prevent similar harm from occurring again.

The purpose of a Safeguarding Adult Review is not to hold any individual or organisation to account – other processes exist for that purpose which include each partner organisation’s own disciplinary procedures – but to focus on the learning.

Where relevant, organisations should contact their governing/regulatory body and ensure that communication about the events leading up to the SAR is transparent.

3.1. A Safeguarding Adults Board (SAB) is the only body that can commission a Safeguarding Adults Review.

As set out in S44 of the Care Act 2014, a SAR must take place when:

• an adult 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
• adult has experienced serious abuse or neglect, but has not died

3.2. “Serious abuse or neglect” may include:

• the individual would have been likely to have died but for an intervention
• the individual suffered permanent harm as a result of abuse or neglect
• the individual has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect
• the individual has sustained a potentially life-threatening injury through abuse or neglect
• the individual has suffered serious sexual abuse.

This is not an exhaustive list. The final decision rests with the LSAB or delegated SAR panel as to whether abuse/ neglect was serious enough to warrant a SAR

3.3. In addition, Safeguarding Adults Boards are also free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

3.4. There is no requirement for a case to have gone through a Section 42 safeguarding adults’ enquiry before it can be considered for a SAR.

3.5. A discretionary SAR should only be commissioned when there is potential to identify sufficient and valuable learning to improve how organisations work together, to promote the wellbeing of adults and their families, and to prevent abuse and neglect in the future.

3.6. Appropriate cases for a discretionary SAR may include:

• serious incidents that do not meet the criteria for a SAR but that the SAB wants to review
• a case featuring repetitive or new concerns or issues which the SAB wants proactively to review in order to pre-emptively tackle practice areas or issues before serious abuse or neglect arises
• a case featuring good practice in how agencies worked together to safeguard an adult with care and support needs, from which learning can be identified and applied to improve practice and outcomes for adults
• the criteria for carrying out a Safeguarding Adult Review is broad and therefore the approach taken should be proportionate according to the scale and level of complexity of issues being examined. A SAR can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults or explore examples of good practice where this is likely to identify lessons that can be applied to future cases

In any Safeguarding Adult Review there is a need to achieve an understanding of:

• what happened
• any errors, absence of good practice or problematic practice and/or what could have been done differently
• why those errors, absence of good practice or problematic practice occurred and/or why things did not happen differently, for example any systemic issues preventing good practice
• which of those explanations are unique to this case and context, and what can be extrapolated for future cases to become recommendations for learning
• whether any of the issues identified were also present in previous reviews and, if so, whether steps have already been taken to improve practice as a result
• what remedial action needs to be taken in relation to the findings to help prevent similar harm in future cases

All Safeguarding Adult Reviews should present clear and concise findings taken from the ‘Information Management Reviews’ (IMRs) and chronologies, responses to queries and questions and analysis by the author.

All Safeguarding Adult Reviews must identify clear, specific, measurable and, realistic recommendations for individual agencies and for the SAB.

A range of methodologies or tools can be used to undertake the necessary investigations to deliver a Safeguarding Adults Review.

No one model will be applicable for all cases.

The focus must be on what needs to happen to achieve understanding and remedial action.

There must always be a consideration of how family and friends can achieve clarity and understand what happened.

Whilst this is not the primary function of a Safeguarding Adult Review, there must always be a consideration of involvement of individuals and families or significant others as appropriate, in contributing to a Review.

The Safeguarding Adults Board Sub-Group will agree:

• the type of ‘review’ process and methodology to be used
• the arrangements for governance of the review and overseeing its development as well as agreeing the draft final review to be placed before the Board for consideration
• the most effective way to promote learning and improvement action
• consideration of how the SAR may also be used to explore examples of good practice where this is likely to identify lessons that can be applied in future

The following principles should be applied by the Safeguarding Adults Board Subgroup to all reviews:

• the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined and will be overseen by the Board through its delivery of a Review and Action Plan
• when the SAR criteria are met, consideration should be given to other statutory and non-statutory reviews which are taking place simultaneously or may have precedence. If other partner organisations’ reviews (e.g., Mental Health Homicide Review, Domestic Homicide Reviews, NHS Serious Incident Reviews or Review by a partner in accordance with their own organisational policies) is taking place, then a decision can be made to put the SAR on hold until the outcome of that review. Additionally, and in some circumstances, it may be appropriate to have sight of the Terms of Reference for that Review and for a request to be made to include issues which might be pertinent to a SAR. In such cases, the other completed Review may be brought back to the SAR Subgroup to then decide whether in fact more work needs to be undertaken or whether the Review as it stands can be considered for a SAR to place before the Board. 
• reviews of cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed (not necessarily an independent overview author)
• relevant professionals should be involved fully in reviews and invited to contribute their perspectives
• where possible, adults at risk are to be involved in a Safeguarding Adult Review, to make a contribution about their own experience. If they have any significant difficulty in being involved an advocate may help them to be as involved as far as possible in the process
• families should be invited to contribute to reviews, where appropriate. They should be informed when a Review has been commissioned and the SAR Subgroup Chair or another appropriate person such as an involved professional should clearly communicate with them so that they understand how they are going to be involved. Their expectations should be managed appropriately and sensitively

The options for conducting a Safeguarding Adult Review are detailed in the appendices, as are the skills required of a SAR Author.

In general, SARs should be completed within 6 months, unless otherwise specified.

The SAR subgroup will seek to identify at the outset what other reviews and processes are taking place or envisaged in relation to the same events.

Where there are possible grounds for a Safeguarding Adults Review and a Domestic Homicide Review or Safeguarding Children Serious Case Review, Multi Agency Public Protection (MAPPA) Serious Case Review, Mental Health Homicide Investigation and/or other such formal review processes, then a decision should be made at the outset by the decision makers involved as to:

• which process is to lead
• who is to take which role
• who is to chair with a final joint report being taken to the necessary commissioning bodies

Whether some aspects of the reviews can be commissioned jointly should be considered so as to reduce duplication for families and professionals.

It will be important that terms of reference for related reviews effectively cover all aspects of the case.

Similarly, NHS bodies carry out Serious Incidents Requiring Investigation (SIRI) and any relevant investigation, which meets the criteria for a SAR, should be shared with the Safeguarding Adults Review Subgroup in order to make best use of resources and information.

Any Safeguarding Adult Review will need to take account of a coroner’s inquiry, and or any criminal investigation related to the case, including disclosure issues, to ensure that relevant information can be shared without incurring significant delays in the review process and in order not to compromise information which can be made available.

A coroner is legally entitled to require information provided to Safeguarding Adult Reviews as well as the overview report itself.

When a Coroner requires information, correspondence will be with the Chair of the Safeguarding Adults Board.

Anyone for example, a member of the public, agency or professional body, elected members, MPs or a Coroner may refer cases to the SAB for consideration for a SAR.

Referrals must be made in writing to the Board Business Manager who will bring it to the attention of the SAR Subgroup Chair and the Chair of the Board.

The SAR Sub-Group will decide, if a review should be recommended (see Appendix 6 Safeguarding Adult Review (SAR) Request Form for relevant forms).

The SAR subgroup acts as an advisory group to the SAB Chair who is responsible for making the decision to recommend to the Safeguarding Adults Board whether to proceed with a review or not.

The Safeguarding Adults Board is responsible for commissioning Safeguarding Adult Reviews.

A decision about whether to undertake a Safeguarding Adult Review should be made within 6 weeks from receipt of the initial request.

The Chair of the SAR subgroup will advise the person making the referral, in writing, of the decision whether to proceed with a SAR.

8.1 Appeals

In the event of a decision being made that the matter does not meet the criteria for a SAR, the reasons need to be recorded by the Chair and shared with the referrer.

If the referrer wants to appeal against a decision not to carry out a Safeguarding Adult Review, it should be put in writing to the Independent SAB Chair, who will review the decision.

The SAB Chair may take legal and other professional advice and s/he will write to the referrer setting out why the referral did not meet SAR criteria or, whether the matter has been reconsidered and explaining what other actions may be taken.

The Safeguarding Adults Board must include information about the findings from any Safeguarding Adult Review in its Annual Report and what actions it has taken or intends to take in relation to those findings.

Where the Safeguarding Adults Board decides not to implement an action then it must state the reason for that decision in the Annual Report.

There will be a need to identify the budgetary requirements for undertaking a Safeguarding Adult Review, which will be the responsibility of the relevant Safeguarding Adults Board.

Where a Joint Review takes place each organisation’s contribution should be agreed at the outset.

Agencies should adhere to the Pan-Dorset Overarching Information Sharing Agreement and Board’s Personal Data Exchange Agreement.

All agencies must ensure that information, including accurate and secure records, required for delivery of the SAR are available for the SAR author, in the time required as requested by the SAR Panel.

Relevant legislation for example the Care Act 2014, Mental Health Acts and Mental Capacity Act 2005 must be adhered to.

The SAR Panel will agree with the SAR Subgroup Chair a list of issues to be included in any media and communication strategy.

The strategy will be agreed between the SAR Subgroup Chair and the SAB Chair.

Action plans resulting from a Safeguarding Adult Review recommendation need to be SMART with robust outcomes that can be monitored and measured:

• they should be clearly achievable within timescales considered
• consideration should be given as to whether the action plan is also published with final report on the Board website, if the full SAR is published

The SAR Subgroup will need to include a Draft of the SAR Action Plan to be submitted to the Board for decision alongside the final Draft SAR report.

Completion of actions in the plan will be monitored by the SAR subgroup and reported regularly to the SAB.

A review will only be closed when the SAB is satisfied that all the actions have been completed.

The relevant Board subgroups will determine if there should be any longer term follow up of the impact on practice of the recommendations of the review as part of its annual audit plan.

Learning and dissemination of learning from Safeguarding Adult Reviews will be led by individual agencies with oversight by the appropriate SAB subgroup.

A range of methods for disseminating and briefing staff will be used, including formal learning events, on-line learning and 7-minute briefings.

Any new learning will also be integrated into regular adult safeguarding training programmes.

Each partner agency will be asked to assure the SAB that they have allocated sufficient time and resource for staff to integrate the lessons into practice.

SARs will usually be published and placed on the SAB website.

Where there are exceptions to publication, e.g., to protect anonymity of the subject or their family members, these will have been agreed by the SAB at the time the SAR was presented and agreed.

In all circumstances and in particular where there may be public interest in the findings of a review the Board will take a more proactive stance and in line with a Media Communications Strategy take the appropriate steps.

In these circumstances the SAB will work alongside and expect that partner Communication Leads are proactive and working together with one Lead Agency with joint press release and FAQs.

The Chair of the Board will act as the spokesperson on behalf of the Board.