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Safeguarding Adult Reviews (SARs)

The Care Act states that the safeguarding adults board must arrange a safeguarding adults review in some circumstances – for instance, if an adult with care and support needs dies as a result of abuse or neglect and there is concern about how one of the members of the safeguarding adults board acted.

The reviews are about learning lessons for the future. They will make sure safeguarding adults boards get the full picture of what went wrong, so that all organisations involved can improve as a result.

The purpose of a serious case review is not to re-investigate or to apportion blame. It is to:

  • Establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults with care and support needs;
  • 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); and
  • Prepare or commission a report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action.

There is no requirement for a case to have gone through a Section 42 safeguarding adults enquiry before it can be considered for a SAR. However, there should be multi-agency involvement in the case and a likelihood that multi-agency learning can be identified.

A SAR may be arranged by NYSAB for any other case involving an adult in its area with needs for care and support. A non-statutory SAR should only be commissioned when it is clear that there is potential to identify sufficient and valuable learning to improve how organisations work together, to promote the wellbeing of adults and their families, and to prevent abuse and neglect in the future where the case does not fully meet the criteria for a statutory SAR.

Appropriate cases for a non-statutory SAR may include:

  • Serious incidents with multi-agency involvement that do not meet the criteria for a statutory SAR but that NYSAB wants to review as it is likely that multi-agency learning can be identified.
  • A case featuring repetitive or new concerns which NYSAB wants to review in order to pre-emptively tackle practice areas or issues before serious abuse or neglect arises; or
  • A case featuring good practice in how agencies worked together to safeguard an adult with care and support needs, from which learning can be identified and applied to improve practice and outcomes for adults.

Safeguarding Adults Review Policy

This document provides guidance on the North Yorkshire Safeguarding Adults Board (NYSAB) Safeguarding Adult Review (SAR) Framework. It is designed to assist people to decide when to refer a case for consideration as a SAR, as well as providing guidance on the SAR process itself.

SAR Policy

SAR Policy

Referral Form

Safeguarding Adult Review in Respect of ‘Ian’

This review looks at the actions of the agencies involved in supporting ‘Ian’ a gentleman who died in 2017 after taking his own life. The review looked specifically at the multi-agency response to Ian’s needs in the period prior to his death. We thank Ian’s family for their help with this review during this difficult time for them.

The report makes a number of recommendations to the individual agencies involved and the SAB as a whole, all of which are accepted by the SAB in full. As agreed with his family, the pseudonym of ‘Ian’ has been used for this review.

Review of “Mr K”

North Yorkshire Safeguarding Adults Board has recently been involved in a review concerning a 46 year old White British man with learning disabilities and other complex medical conditions (Mr K). The review was carried out using methodology used for Learning Disability and Mortality Reviews and was undertaken in partnership with Kirklees Safeguarding Adults Board and Leeds Safeguarding Adults Board.

The review found a number of areas of good practice of those who supported Mr K throughout his life. No abuse or neglect was identified. In contrast, the review identified positive partnership working in caring for Mr K and noted the dedication of those in North Yorkshire who worked with him.

Further information about the review and its findings can be found on the Kirklees Safeguarding Adults Board website at the following link: https://www.kirklees.gov.uk/beta/adult-social-care-providers/pdf/learning-from-a-recent-review.pdf

Lessons Learned Reviews of ‘Mrs S’

Two independent Reviews were commissioned by the North Yorkshire Safeguarding Adults Board regarding ‘Mrs S’. The first of these, an independent Lessons Learned Review was following a number of safeguarding alerts and complaints raised by one of Mrs S’ daughters between 2013-2017 regarding her mother’s care in a nursing home.

In the time since this review was commissioned Mrs S has sadly passed away. To assure the Safeguarding Adults Board that Mrs S received quality care and treatment, and that any multi-agency lessons are identified and acted upon, a second independent case review which evaluated the care and treatment of Mrs S in the final weeks of her life has also been completed.

Both reports can be viewed below, together with a response to the reports from one of Mrs S’ daughters.

DS Delivery Report

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Safeguarding Adult Review in respect of Mrs A, March 2018

This review looks at the actions of the agencies involved in supporting Mrs A, an 88 year old lady, who died on 4 June, 2015.  This review has identified that although there is nothing that could have been done to prevent the death of Mrs A and that she had made clear decisions about her own care and support, the agencies working with patients need to weigh these wishes carefully against professional practice standards.  The review has recommended a rolling programme of training for all workers to ensure they have safeguarding training appropriate for their job and that there are clear processes available for families and others to raise concerns and complaints.

More Information

Serious case review in respect of ‘Robert’

In 2013, North Yorkshire Safeguarding Adults Board published a serious case review into the death of ‘Robert’.

The review recommended actions or learning points for the agencies involved and for the safeguarding adults board. The recommendations in the report were accepted fully by the board as a means to further professionals’ understanding, support wider knowledge sharing and improve services for homeless people in this complex and unique area of adult social care.

The board is now satisfied with the response to all the recommendations and formally signed off the action plan at its meeting on 5 June 2014.

In addition it agreed to issue a staff/partners briefing note with case briefing sheet for communication and awareness raising about the outcomes put in place from the serious case review action plan.

The board recommends that this briefing note is used by staff and trainers within the relevant agencies to encourage understanding and learning from this review.

The board has also adopted an updated serious case review protocol which reflects the lessons learned from this review which will be operational with immediate effect, pending a further review alongside the guidance about safeguarding adults reviews in the Care Act (2014). This protocol is available above.

A joint procedure has also been issued which clarifies the response that homeless people should receive if they present out of hours to health and adult services or district councils. The procedure has been developed jointly between Health and Adult Services and the County Homelessness Group.

More Information

Lessons Learnt Report – Alexander Court

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