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Berkshire Safeguarding Adults
Policies and Procedures
2. Adult Safeguarding Policy

2.9 Safeguarding Adult Reviews (SARs)

Section 44, the Care Act 2014 stipulates that SABs must arrange a SAR when an adult in its area with care and support needs 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 with care and support needs, in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect.

The duty to arrange a SAR arises regardless of whether or not there has previously been an enquiry into the case by the Local Authority or by another agency, such as a Coroner, however, such an enquiry may identify that a SAR is required.

In the context of SARs, something can be considered serious abuse or neglect where, for example the individual was likely to have died but for an intervention, or 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 criteria are met when:

  • An adult at risk dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in their death; or
  • An adult has sustained a potentially life threatening injury through abuse, neglect, serious sexual abuse or sustained serious and permanent impairment of health or development through abuse or neglect; and one of the following:
    • Where procedures may have failed and the case gives rise to serious concerns about the way in which local professionals and/or services worked together to safeguard adults at risk;
    • Serious or apparently systematic abuse that takes place in an institution or when multiple abusers are involved. Such reviews are likely to be more complex, on a larger scale and may require more time;
    • Where circumstances give rise to serious public concern or adverse media interest in relation to an adult/adults at risk.

There is an expectation that individuals, agencies, organisations, cooperate with the review but the Act also gives Boards the power to require information from relevant parties.

2.9.1 Criminal investigations and police involvement

The Thames Valley Police Serious Case and Domestic Homicide Review Team was set up in April 2010 to deal with all IMR requests relating to vulnerable people. The selected team of officers are all accredited detectives or Specialist Investigators with a background or knowledge in at least one strand of the Protecting Vulnerable People disciplines of Child Abuse, Domestic Abuse, Serious Sexual Assault and Adult at Risk investigations. The team are dedicated to IMR investigations and as such continue to develop a high level of expertise in the preparation of these documents. Members of the team also attend a nationally recognised Reviewers’ course.

The team are entirely independent of any investigation or Police action for which IMRs are requested. Should any member of the team have any knowledge or involvement in an allocated case they will declare this interest and the case will be reallocated for completion. Each completed IMR, with any subsequent recommendations, is submitted to a Quality Assurance Panel which could include the PVP Detective Chief Inspector (DCI) or a PVP Detective Inspector (DI) and a DI from the Crime and PVP Strategy Unit for the Force. Membership of the Quality Assurance Panel is dependent on which member of staff is the TVP representative on the relevant Review Panel. In any case, the Quality Assurance Panel will be chaired by an officer of at least the rank of DCI and will include the TVP Review Panel member.

They are responsible for quality assurance against the set parameters of the IMR, to ensure the recommendations made are appropriate and relevant, to take responsibility for any organisational learning and to be certain that the IMR does not encroach upon any live investigation which might have an adverse impact through disclosure on any outcome of the case. This may involve liaison with the Senior Investigating Officer (SIO) and the Crown Prosecution Service (CPS) where necessary. Once satisfied, the PVP Detective Chief Inspector (DCI) will complete the final sign-off and accept ownership of the resulting action plan. In order to ascertain any involvement of TVP for the relevant time period covered by the review all appropriate databases and systems, listed below, have been checked for information relating to the relevant people.

2.9.2 Outside of SAR remit

Where the SAB agrees that a situation does not meet the criteria but agencies will benefit from a review of actions other methodologies can be considered. These include:

  • Serious Incident Review: Organisations should use their own SI procedures if this is deemed suitable and special consideration should be given to the involvement of relevant partner organisations.
  • Management Review: A review by an individual organisation in relation to their understanding and management of a particular safeguarding issue.
  • Reflective Practice Session: The original participants in the case may review identified aspects of the case as part of a reflective practice session chaired by the Safeguarding Lead or other such suitable person, including an independent facilitator.
  • ‘Learning Together’: A collaborative scrutiny approach to a case.

2.9.3 Principles

SARs should reflect the six adult safeguarding principles and be conducted within a framework of openness and transparency.

2.9.4 Purpose

The purpose of all SARs is to keep the focus on learning. The final SAR report and those responsible for disseminating the learning from it, should ensure that the recommendations can be translated into practice, not just for those involved but to a wider audience to support prevention strategies and influence strategic plans.

It is not for a SAR to investigate how a death or serious incident happened. Neither is it the responsibility of the SAR to apportion blame. Such matters will be dealt with by the Coroner or criminal courts, or other bodies.

2.9.5 The Adult

In non-fatal cases, the views of the adult or representative should be central to the decision making process about the type of SAR to undertake. Communication should be established at the earliest opportunity and advocacy provided to support the adult. Information should be given about how the SAR will be conducted and how they can be involved or, in the event that the adult has deceased, how nominated people can be involved.

Where there is a police led investigation, close contact with any appointed police Family Liaison Officer should be made. Communication should be clear and consistent between all designated supporters including independent advocates. See section 2.9.1 above in relation to cases where there is an ongoing criminal investigation or criminal proceedings.

2.9.6 Person alleged to have caused harm

The emphasis on learning should include the person alleged to have caused abuse or neglect so they can adjust their behaviour, act differently and reflect upon the impact that they might have had on others. This may involve liaison with other professionals, working with, or trained to work with people who abuse.

2.9.7 Advocacy

The Local Authority must arrange, where necessary, for an independent advocate to support and represent an adult who is the subject of a SAR. Where the adult is deceased, it is good practice to provide advocacy to family/friends (see sections 3.1.1, 3.2.1 and see Appendix 1) to ensure outcomes of the individual are supported.

2.9.8 Carers

The desired outcome, especially where a family is bereaved, needs to be approached with sensitivity. Consultation and involvement needs to be balanced with the overall wellbeing of the individuals involved. Throughout the process due diligence, compassion and appropriate support should be provided and the relevant Local Authority community team should be available to provide this or an alternative arranged if more appropriate.

2.9.9 Staff

There will be occasions when allegations are made that staff have been guilty of abuse against adults at risk.

If the staff member is subject to a disciplinary enquiry, it is likely that the SAR will work alongside the disciplinary enquiry. However, certain disciplinary enquiries may lead to a criminal investigation. The decision to run a SAR alongside any disciplinary enquiry will be made on a case by case basis. The final decision will be made by the Independent Chair of the Safeguarding Adults Board. 

2.9.10 Who should undertake a SAR?

The individual commissioned to undertake the SAR should be independent of the organisations involved. They should have the appropriate core skills including:

  • Strong leadership and ability to motivate others;
  • Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
  • Collaborative problem solving experience and knowledge of participative approaches;
  • Ability to find and evaluate best practice;
  • Good analytic skills and ability to manage quantitative and qualitative data;
  • Knowledge of safeguarding adults;
  • Ability to write for a wide audience; and
  • An understanding of the complexity of the health and social care system.

2.9.11 Requests

Any individual, agency or professional can request a SAR. This should be made in writing to the SAB Chair, or as agreed by the local SAB. The request should detail:

  • What happened, with dates if known;
  • The views of the adult/family/carer;
  • Where the incident/concerns took place;
  • Who was involved and their organisation; and
  • Why the request is being made.

The request should be considered against the criteria in order for a SAR process to be consistently applied. Agreement to a SAR should be recorded on relevant systems across the statutory agencies. For the NHS this will be carried out by the CCG who will record on STEIS.

2.9.12 Commissioning a SAR

The SAB is the only body authorised to commission a SAR and decide when a SAR is necessary; arrange for its conduct and if it so decides, to oversee implementation of the findings. Where the SAB decides to reject recommendations it must state the reason for that decision in its Annual Report.

The SAB may convene a subgroup to act on its behalf to receive and manage requests, and have delegated commissioning responsibilities. In commissioning a SAR, there may be procurement or other commissioning protocols to consider and it may be helpful to establish these as part of the governance arrangements.

SAR options - A number of options may be considered by the SAB or delegated subgroup. The SAR model should be determined locally according to the specific individual circumstance. Models of a SAR have been identified by SCIE. Safeguarding Adults Reviews: implementation support for SABs to weigh up the most appropriate and proportionate response to the situation. No one model will be applicable for all cases. The focus must be on what needs to happen to achieve understanding, take remedial action and, very often, provide answers for families and friends of adults who have died or been seriously abused or neglected. Every effort should be made while the SAR is in progress to capture points from the case about improvements needed and to take corrective action.

When commissioning a SAR the following points should be agreed:

  • Scope of the terms of reference; 
  • Knowledge, skills and experience of the reviewer; 
  • Timescales for completion; 
  • Who will secure any legal advice required; 
  • How quality assurance will be managed;
  • How the interface between the SAR and any other investigations or reviews will be managed; 
  • A communication strategy, including clarification about what information can be shared, when and where (conditions);
  • A media strategy; 
  • What the arrangements for administrative and professional support are, and 
  • How it will be paid for.

2.9.13 Links with other reviews and investigations

All statutory agencies leading investigations following a death need to be aware of potential parallel inquiries, investigations and processes which may have been instigated as a result of the death.  

For victims of domestic homicide, there is separate statutory guidance in respect of children, which provides for a

These two sets of statutory guidance overlap where the victims are aged between 16 and 18.

When commissioning a SAR there should be consideration of how it will dovetail with other statutory reviews and any other investigations.

The guidance for DHR states consideration should be given to how the child SCRs and DHRs can be managed in parallel in the most effective way, so that organisations/professionals can learn from the case. Different types of reviews will have their own specific areas of investigation and these should be respected. Where intelligence can be shared across reviews, there should be no organisational barriers to information sharing. It is also helpful to consider if some aspects of the reviews can be commissioned jointly to reduce duplication.

2.9.14 Coroners

Any SAR may need to take account of a Coroner‘s inquiry, including disclosure issues, to ensure that relevant information can be shared without incurring significant delay. Coroners are independent judicial office holders who are responsible for investigating violent, unnatural deaths or deaths of unknown cause, and deaths in custody, or otherwise in state detention, which are reported to them. The Coroner may have specific questions arising from the death of an adult at risk. These are likely to fall within one of the following categories:

  • Where there is an obvious and serious failing by one or more organisations;
  • Where there are no obvious failings, but the actions taken by organisations require further exploration/explanation;
  • Where a death has occurred and there are concerns for others in the same household or other setting (such as a care home);
  • Deaths that fall outside the requirement to hold an inquest but follow-up enquiries/actions are identified by the Coroner or his or her officers.

In the above situations the local SAB should give serious consideration to instigating a SAR.

2.9.15 Findings from SARs

The Home Office, Domestic Homicide Review Toolkit Guide to Overview Report Writing offers a helpful steer on the production of reports, so that they satisfy families, public, professionals and others who will read the report and look to it for explanation and for reassurance that it has captured the essence of any learning needed to improve services and reduce the likelihood of future similar incidents.

SCIE has suggested that SABs can take advantage of data from other quality assurance and feedback sources such as audits and complaints, to inform decision making about the kind of case or issue that would benefit the review. The review formally concludes when agreed by the SAB.

The findings and outcomes of any SAR should be captured within the Annual Report of the local SAB.

 2.9.16 Timetable

The timescale from the decision to conduct a SAR to completion is 6 months. In the event that the SAR is likely to take longer for example, because of potential prejudice to related court proceedings, the adult/advocate and others should be advised in writing the reasons for the delay and kept updated on progress.