Adult Serious Case Reviews

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Adult Serious Case Reviews

• Jill Manthorpe

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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.

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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!

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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

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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 under-developed
  ways of monitoring recommendations
• Delays frustrating but explicable

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Looking at 22

• Communication problems 17
• No lead agency 5
• Training needed 13
• Whistle-blowing problems 3

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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

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Thinking systems (Munro)

• Recognise staff are neither autonomous or puppet
• Why did poor practice happen?
• Improve learning
• Think sailing boat not train..

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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

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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)
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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 inter-agency
  practice
• to make recommendations for future practice and
  to provide explanation and insight for Bills
  relatives

Serious Case Review Executive Summary Bill
The Cumbria Safeguarding Adults Board wish to
express sincere condolences to Bills family.
2009 Logos of County Council, NHS Police
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Example 4

• What next
• London Borough of Merton illustrates keeping on
  the books approach

• Recommendations
• 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

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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.

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(No Transcript)
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Legal arenas

• In contrast to child care law, adult social
  carehas developed piecemealit remains a
  confusing patchwork of conflicting statutesit 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

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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

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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)
• Persons 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)  

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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

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future

• Thinking about
• Statutory Safeguarding Boards (decided)
• Enhanced duty of cooperation
• Duty to investigate/ make enquiries
• And more..

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Thank you

• P.S. Please send us any SCRs you think we have
  missed !
• Contact details
• e-mail jill.manthorpe_at_kcl.ac.uk