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.
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Adult Serious Case Reviews
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
‘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
Parkfields Care Home
Overview report by Margaret Sheather, Independent chair of the Review
Executive Summary of the Serious Case Review in respect of
Author: Margaret Williams
Apx 3: Key people/organisations involved with Adult A page61/65 (excluded neighbours)
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 Bill’s relatives
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’
‘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.
‘No Secrets’ DH 2000 (England & Wales)
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…
Emphasis on mental capacity at the centre of decisions JusticeHedley: 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. JusticeMunby -A & C  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)
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
P.S. Please send us any SCRs you think we have missed !