Implementing
the Significant
Incident Learning
Process (SILP)
Heather Pick
Assistant Director
Personal Care and Support
Leicestershire County Council
Heather.Pick @leics.gov.uk
Helen Pearson
Board Officer
Leicestershire and Rutland
Safeguarding Adults and Children
Board
helen.pearson@leics.gov.uk
Pilot Project Background
East Midlands Joint Improvement Partnership
Safeguarding and Dignity Board reviewed Serious
Case Review function and process :
 Concerns that SCR’s are not always used
effectively
 No standardised practice/lack of consistency
 Time consuming and resource heavy
 Quality of IMRs vary
 Lessons learnt not always disseminated in a
timely fashion
 Much of the process can be remote from
frontline practice, lessons get lost
PROJECT OUTCOME 1
Quality Assurance Framework for Benchmarking
Standards in the Commissioning and
Delivery of the East Midlands Safeguarding
Board for conducting SCR’s and SILP’s in the
region
Commissioning Tools
and
Templates
Project Outcome 2
SILP Pilot Process
 Facilitate
a ‘live’ SILP process
 Evaluation of process and learning outcomes
 Inform on any required changes to the
process
 Cost analysis
 Lessons for all on a new process
SILP Criteria




1. Where an adult who may have been in need of
safeguarding dies or experiences serious harm where
this is not due to direct abuse but there is evidence of
self- neglect and/or refusal of service AND there may
be concerns about their capacity to self- care and
understand the consequences of not doing so.
2. Multiple incidents or concerns with increasing
frequency and severity within an institutional setting
or involving the same provider agency.
3. Serious harm and/or abuse was likely to occur but
has been prevented by good practice.
4. Where there are seen to be high levels of public or
media interest in an incident
Aims of the SILP
 Learn
and own lessons
 Openness and critical analysis
 Individual and organisational practice
 Why decisions were made and actions
taken/not taken.
 Address changes to practice
 Consider how changes will happen
 SMART recommendations
What SILP is not……
 SILPs
are not inquiries into how a vulnerable
adult died or was harmed or who is culpable that is a matter for Coroners and criminal courts
 SILPS
are not a part of any disciplinary enquiry or
process
Managing the SILP process
 No
legislative framework
 No statutory timescales
 Shared Learning Experience
 New experience for all services
SILP Process
• SCR Subgroup – recommend SILP
• Chronology/ summary report writer and
front line staff identified
• Briefing session – TOR and Hopes and
fears.
• SILP Learning Event
• Report/Lessons
• Feedback Event /Action Plan
SILP CASE Background
 Two
Learning Disabled adult males
 Sexual assault by one against another in
the toilet.
 College setting – Adult Education class
 Perpetrator supported by PA employed
by parent.
Those involved
 Police
 MAPPA
 Adult
Social Care – Learning Disability
Team
 Community Opportunities
 Health Learning Disability Nursing Services
 Adult Learning
Learning from SILP






Adult Ed -changes to course enrolment forms
Community Ops Project – Poster for notice
board
Training for Police re Learning Disabled adults
as alleged perpetrators
Recording of sexually inappropriate
behaviour ( clarity and transition child-adult)
Adult Social Care – responsibility for sharing
information to PA’s
Clarified issue of access to Psychological
service during investigation process
Learning – Pilot and subsequent SILP
Positive process for those involved if:
 Address hopes and fears
 Timing of SILP ( other process)
 Getting the right people involved
 Ensuring all contributions are obtained and
valued at events
 Consider how to involve subject/family
 Combined Chronology ( time line /key events)
 Agreeing lessons learned
 Confidentiality
 Cost
 Skilled Facilitators