Safeguarding Adults Reviews
The Care Act 2014 introduces statutory Safeguarding Adults Reviews (previously known as Serious Case Reviews), mandates when they must be arranged and gives Safeguarding Adult Boards flexibility to choose a proportionate methodology.
A protocol has been developed in the light of the Care Act 2014 and the guidance contained within Chapter 14. This is available on the Multi Agency Policy & Procedure web page Multi Agency Safeguarding Policy and Procedures & supporting guidance
Safeguarding Adult Review's (SARs) should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied in practice to prevent similar harm occurring again.
The purpose of the reviews are not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.
It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them. If individuals and their organisations are fearful of SARs their response will be defensive and their participation guarded and partial.
Out of County SARs
Gloucestershire Safeguarding Adults Board extends our full sympathies to Laura’s family. Whilst this Safeguarding Adult Review was undertaken by Warrington SAB, we accept the findings of their report and wish to provide further assurance that our Partnership is committed to learning from her tragic death. GSAB is acting to consider all recommendations, with a focus on the two that pertain to local systems development:
Recommendation 7: WSAB and GSAB should seek assurance within their areas that local service provision for service users diagnosed with personality disorders should meet NICE guidelines and be available to all those in need of such services without waiting times that put individuals at risk.
Recommendation 8: The WSAB should assure itself that providers are aware of the Carers’ Trust’s standards, which are set out in the ‘Triangle of Care’ approach, and have adopted those standards or have plans in place to do so.
Gloucestershire Safeguarding Adults Board is seeking assurance that the two recommendations are being taken forward and we will provide a written update on the website in due course. The role of the Board is to ensure that the recommendations are taken forward by the relevant partner agencies in order to bring about positive change.