Ridout Report – Learning Lessons: Do Safeguarding Adults Reviews work?

Topics covered: Ridouts professional advice

Look at a Safeguarding Adult Review (“SAR”) Report (and indeed a Serious Case Review report) and you can probably have a fair guess at some of the recommendations it makes before even reading the content – Improve information sharing between agencies; question and challenge; and escalate concerns earlier and higher up the chain of command.

These themes arise time and time again which raises the question of do SARs work and are lessons being learned?

A Safeguarding Adults Board must arrange a SAR when:

– An adult in its area with needs for care and support (whether or not that local authority is meeting any of those needs) dies as a result of abuse or neglect (known or suspected, pre-or post-death); or

– where the adult is still alive but has experienced serious neglect or abuse; and

– there is reasonable cause for concern about how the SAB and partner agencies worked together to safeguard the adult.

The purpose of the SAR is to identify lessons to be learned from the case in point and to apply those lessons to future cases to reduce the change of the incident happening again.  An SAR should not attribute blame to anyone but, of course, it is very difficult not to attribute blame, even inadvertently, to agencies who may have failed to do something that would have protected the adult concerned.  Whilst a SAR is not, in itself, a criminal or civil process, such processes may flow from the circumstances that warrant an SAR and therefore understandably agencies may not be as open and transparent as an SAR aims to be.

Where an adult has died the focus is likely to be on the care provider who was providing care services to the adult at the time of the death, be it a care home or a domiciliary care agency, despite multiple agencies being involved.  They are the agency who is likely to have had the most day to day involvement with the adult concerned.

However, even where other agencies involved with the adult come under criticism the impact of this is likely to be short-lived.  A few “heads” might “roll” in local authorities, health authorities or the police and there may be adverse media interest but as public authorities they will continue to exist and their roles and remit will remain steadfast.  However, where a care provider becomes the focus of any perceived failings, reputations can be damaged.  Placing authorities may decide to no longer place with the provider or, worse still, remove service users.

The ability of a SAR to truly get to the bottom of what happened can be limited.  Each agency that had involvement with the adult must produce an Independent Management Review report which reports on the particular areas/issues identified by the SAB in the SAR’s Terms of Reference.  The Terms of Reference scope the review. These should not be made on assumptions (at Ridouts we’ve seen a serious case review proceed on the basis that the person committed suicide, despite a coroner determining accidental death) otherwise they run the risk of directing parties towards a particular conclusion.  A chronology must also be produced by each agency which provides detail of interactions and events involving the adult, decisions made and actions taken or not taken.

Each agency produces its own Individual Management Report (“IMR”).  Herein lies the need for agencies to keep good records.  How are facts going to be established, especially if the adult concerned cannot be asked?  Often, the scope of SARs span many months, if not years and even if agencies speak to staff, how clear is their recollection of events going to be?

It is not usual for agencies to see of comment on other agency reports.  However, an Overview Report Writer uses the IMR’s reports to write the Overview Report – they do not undertake their own investigation or look at source material – they merely use the IMR’s that have been produced by each agency.  The Overview Report can only be as good as the IMRs produced and whilst the SAR process should not be adversarial, parties should be given the opportunity to challenge other agencies assertions if they are wrong.  Without a full picture, any lessons will be meaningless and could be incorrect if a thorough review is not undertaken.

All SARs will consider if the death was predictable and preventable.  An overview of events, as they occurred, may lead a body to conclude that they were.  However, agencies must be careful when considering these questions as they will be looking at the event with the benefit of hindsight.  Hindsight can distort the decision-making process and conclusions drawn.  Matters should be reviewd on the facts, as presented, at the time.

Producing IMRs and Chronologies can be extremely time consuming.  Individuals who complete these have day jobs too and the pressure to turn around comprehensive documents in a small time frame could result in flawed documents being produced.  It is very important for any provider who finds itself partaking in a SAR to ensure that the documentation submitted as part of the process contains everything it wants to say.  If itiis not in your paperwork, it will not be reflected in the Overview Report or, in turn the Executive Summary.  All too often, agencies focus on the negatives and their failings and whilst it is important to recognise these in order to learn from them, it is also important to recognise good work undertaken.

A question arises whether more SARs will lead to any real changes being made within the social care sector and a reduction in safeguarding incidents.  There needs to be a culture shift that everyone is responsible for safeguarding and responsibility does not fall to someone else but where multiple agencies are involved with an adult there needs to be someone responsible for overall oversight and joined up working.  How do we deal with multiple individuals in multiple agencies working in isolation from each other?

We don’t need another SAR to tell us we need to learn the same lessons, again.


Author Caroline Barker, Partner
0207 317 0348

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