Adult Serious Case Reviews
Jill Manthorpe
What are Adult SCRs?
Definitions vary
•
Internal – external (even high profile)
•
Called many names
•
Public – private
•
Single or group/institution
•
Crossover with complaints/
reviews/management inquiries….
Thresholds for SCRs
• Death – serious harm/concerns of vulnerable
adult
• Institutional practices
• Problems with agency communications or
relationships
• Safeguarding Board concerns
• Pressure - championing
• Fit with policy & procedures
• Panorama + media – something must be done!
Current policy says
(most LAs adopted)
• Permissive (No Secrets)
• ADASS (2006) purpose is ‘not to reinvestigate nor to apportion
blame’
• To ‘establish whether there are lessons to be learnt from the
circumstances of the case about the way in which local
professionals & agencies work together to safeguard vulnerable
adults
• & review the effectiveness of procedures (both multi-agency and
those of individual organisations)
• & inform and improve local inter-agency practice
• & improve practice by acting on learning (developing best practice)
• & prepare or commission an overview report which brings together
and analyses the findings of the various reports from agencies in
order to make recommendations for future action’
Chairs told us
• Get admin support (and
support for them)
• Know how to unlock
doors
• Build up experience
• Keep process going
• Not always in control
• Limited call back to
review
• Independent chair not
always necessary
• Independence has its
uses (& costs)
• Little knowledge of
learning – underdeveloped ways of
monitoring
recommendations
• Delays frustrating but
explicable
Looking at 22
•
•
•
•
Communication problems 17
No lead agency
5
Training needed
13
Whistle-blowing problems 3
discretion
• No set process – so decide !
• Identify resources
• Agree purpose & terms of reference
• Present chronology & facts, missed
opportunities, think system
• Ascertain co-operation
• Establish ways to monitor & learn
Thinking systems (Munro)
• Recognise staff are neither autonomous or
puppet
• Why did poor practice happen?
• Improve learning
• Think sailing boat not train..
Example 1: content
• ‘The report has four main
elements after the
introductory sections:
good practice that was
noted, lessons that have
been learnt, changes in
policy and practice that
have been made since
the events, and
recommendations for
action to improve adult
safeguarding further’.
(+Action Plan 37pp)
Somerset Safeguarding
Adults Board
Serious Case Review
concerning
Parkfields Care Home
Overview report by
Margaret Sheather,
Independent chair of
the Review
May 2011
Example 2
Executive Summary of the
Serious Case Review in
respect of
Adult A
DOB: 03/07/1945
DOD: 10/03/2010
Author: Margaret Williams
Apx 3: Key
people/organisations
involved with Adult A
page61/65 (excluded
neighbours)
Example 3: terms of reference
Terms of reference for the SCR as
established by the Board.
• To establish the circumstances
and events surrounding the death:
• to examine the management of his
care by individual agencies;
• to review the effectiveness of both
multi agency & individual policies
and procedures and operational
methods & examine the probability
of whether any changes would
have changed the outcome;
• to inform and improve local interagency practice;
• to make recommendations for
future practice and to provide
explanation and insight for Bill’s
relatives
Serious Case Review
Executive Summary
“Bill”
The Cumbria Safeguarding Adults Board
wish to express sincere condolences to
Bill’s family.
2009
Logos of County Council, NHS & Police
Example 4
• What next
‘Recommendations
•
• London Borough of
Merton illustrates keeping
on the books approach
•
The SGAB will ensure
that all
recommendations are
actioned and will
request updates from
agencies
The action plan will
remain on the SGAB
Agenda until such time
that all
recommendations have
been implemented’
Fear of SCR
‘Following the Serious Case Review,
ensure a more systematic approach to
reviews in the learning disability service,
particularly emphasising quality and
outcomes.’
Extract from CSCI report to a Local Authority
2007 - feeling that they were ‘hung out to
dry’ by making SCR public.
Government
Policy
Legislation
and case law
No Secrets
Consultation
Inquests,
Inquiries and
research
Legal arenas
• ‘In contrast to child care law, adult social
care…has developed piecemeal…it
remains a confusing patchwork of
conflicting statutes…it is characterised by
the sheer volume of legislation with much
overlap & duplication. It is noted for its
‘baffling and tortuous complexity ..’
• Re A – per Munby J
Legal/Practice Terms
‘No Secrets’ DH 2000 (England & Wales)
• ‘In the absence of explicit, comprehensive legislation on
adult protection, DH guidance instead defines vulnerable
adults, characterises different forms of abuse and sets
out a framework..’ (Mandelstam, ‘Safeguarding Adults
and the law’ see SCIE 2011)
• Defining a ‘vulnerable adult’
A person ‘who is or may be in need of community care services by
reason of mental or other disability, age or illness; and who is or
maybe unable to take care of him-or herself, or unable to protect
him-or herself against significant harm or exploitation’ (DH 2000)
– but contentious, also described as adult in vulnerable
situations or adult at risk…
Case Law
•
Emphasis on mental capacity at
the centre of decisions Justice Hedley: Re Z
(Local Authority: Duty (2004) EWHC 2817 (Fam).
•
Social care and health services
are there to support not to control
– seek authority from the court.
Justice Munby -A & C [2010] EWHC 978 (Fam)
•
Person’s rights to live with risk
‘What good is making someone
safer if it merely makes them
miserable?’ Justice Munby MM (An Adult) (2007) EWHC
2003 (Fam), (2009)
•
Recognise undue influence and
coercion affecting capacity – role
is to intervene to reduce the levels
of coercion Re SA (2005) EWHC 2942 (Fam)(Case
related to forced marriage) – Justice Munby
(JE 2009 unreported)
Existing Legislation
• Human Rights Act 1998
• Mental Capacity Act 2005
amended 2007 (DoLS)
• NHS & Community Care Act
1990
• Health and Social Care Act
2008 – regulation; direct
payments
• Equalities Act 2010
• Domestic Violence Crimes and
Victims Act 2004
• SVG Act (vetting & barring)
• ……… and the rest!
Law Commission Review April
2011
future
• Thinking about:
– Statutory Safeguarding Boards (decided)
– Enhanced duty of cooperation
– Duty to investigate/ make enquiries
– And more..
Thank you
P.S. Please send us any SCRs you think we
have missed !
Contact details
e-mail: jill.manthorpe@kcl.ac.uk