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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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what are adult scrs
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
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
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 – under-developed ways of monitoring recommendations

Delays frustrating but explicable

Chairs told us
looking at 22
Looking at 22
  • Communication problems 17
  • No lead agency 5
  • Training needed 13
  • Whistle-blowing problems 3
  • 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
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


Parkfields Care Home

Overview report by Margaret Sheather, Independent chair of the Review

May 2011

Example 1: content
example 2
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 inter-agency practice;

to make recommendations for future practice and to provide explanation and insight for Bill’s relatives

Example 3: terms of reference
  • 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

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’

Example 4
fear of scr
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.

legal arenas
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
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 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 [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)  

Case Law
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

Existing Legislation
  • Thinking about:
    • Statutory Safeguarding Boards (decided)
    • Enhanced duty of cooperation
    • Duty to investigate/ make enquiries
    • And more..
thank you
Thank you

P.S. Please send us any SCRs you think we have missed !

Contact details