Safeguarding Adult Review Policy
This policy 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.
1.1 The Care Act 2014 provides a statutory basis for learning and review processes. Safeguarding Adults Reviews (SARs) provide an opportunity to learn lessons when abuse or neglect is suspected to be a factor in the death or serious harm of an adult with care and support needs.
1.2 It is the responsibility of all partner agencies to make a referral for a SAR where there are reasonable grounds to consider the criteria for a SAR have been met. Partner agencies should not draw their own conclusions on whether the criteria are met, but should make a referral to Learning and Review Group (LAR) which is a subgroup of the North Yorkshire Safeguarding Adult Board (NYSAB).
1.3 All partner agencies have a responsibility to ensure that staff know about SARs, their purpose and function. All partner agency staff must know how to refer a case for consideration to the LAR.
1.4 The LAR receives all SAR referrals and considers whether the referral meets the criteria to conduct a SAR, or whether any other action should be conducted to ensure learning takes place.
1.5 The LAR must include senior representatives from the following agencies:
– North Yorkshire Council (NYC) Health and Adult Services (HAS)
– North Yorkshire Police
– Humber and North Yorkshire Health and Care Partnership (ICB)**
– Local NHS Trusts
1.6 The LAR will be considered quorate with representation from the three statutory agencies (police, Local Authority and Integrated Care Board) who are required to have suitably senior designated representatives.
1.7 The NYSAB, via its Independent Chair, is the only body in North Yorkshire that commissions SARs.
1.8 The policy and practice undertaken by the NYSAB strives to reflect the SAR Quality Markers published by the Social Care Institute for Excellence (SCIE). A copy of the markers can be found here: https://www.scie.org.uk/safeguarding/adults/reviews/quality-markers
2.1 The SAR is a statutory learning-focused process, designed to have practical value by illuminating barriers and enablers to good practice, untangling systemic risks, and progressing improvement activities.
2.2 The purpose of a SAR is to determine what the relevant agencies involved in the case might have done differently that could have prevented harm or death. It therefore requires outcomes that:
establish what lessons can be learnt from the particular circumstances of a case in which professionals and agencies were involved in the care and support of an adult at risk of abuse and/or neglect
review the effectiveness of safeguarding procedures, both of individual organisations and multi-agency arrangements
inform and improve future practice by acting on the findings (developing best practice across all organisations)
highlight any good or bad practice identified within the review lead to recommendations that are SMART (specific, measurable, achievable, relevant, time bound)
2.3 Its purpose is 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.
3.1 A SAR must be commissioned when:
an adult in the NYSAB area has care and support needs (whether or not the local authority was meeting any of those needs);
and
b1. either dies, and the NYSAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died)
Or
b2. NYSAB knows or suspects that the adult has experienced serious abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).
and in both cases
there is reasonable cause for concern about how the NYSAB, members of it (or other persons with relevant functions) worked together to safeguard the adult.
The NYSAB has the power to undertake a discretionary SAR in other situations where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults, and can include exploring examples of good practice.
3.3 Following a significant event, active consideration should be made as to whether or not a referral for a SAR is required. To support this, organisations should consider including an appropriate trigger question to include on internal incident reporting, investigation and/or review templates, or have appropriate mechanisms in place to be able to identify scenarios that require referring into the SAR process.
3.4 It is important to note that if the nature of the incident triggers a mandatory investigation or review within the organisation concerned (eg Serious Incident Policy) this should take place without delay and in line with the organisation’s internal policy requirements. Internal governance processes and SARs are not mutually exclusive and indeed, the multi-agency perspective may provide invaluable insights to inform internal review processes and vice versa.
3.5 Section 45 of the Care Act 2014 establishes the importance of organisations sharing with the SAB information relating to the abuse or neglect of people with needs of care and support. If the SAB requests relevant information from an organisation or person (for example, in the context of a SAR) then section 45 of the Act creates a legal duty for that body or person to share what they know with the SAB. The test is that the information requested by the SAB must be for the purpose of enabling or assisting the Board to perform its functions. This includes undertaking SARs.
3.6 In the context of SARs, something can be considered serious abuse or neglect where, for example, the individual would have been likely to have died but for an intervention, or has suffered permanent harm or had reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect.
3.7 When considering a SAR referral, the LAR will need to establish if there is learning from a multi-agency or single-agency perspective. It is important that consideration be given to the increasingly complex landscape of the commissioning and provision of services.
4.1 Some cases may benefit from multi-agency discussion to decide whether a SAR referral is required. NYSAB holds a monthly S44 panel meeting, which provides a forum for multi-agency discussion between statutory partners, of serious cases or scenarios that do not necessarily fit the criteria for a s.42 duty enquiry or cases where there might be multi-agency learning. Meetings are held virtually on Microsoft Teams. At the panel, information is shared by partners in order to reach a consensus to either:
Close the case with no further action required
Escalate the case for consideration for a Safeguarding Adult Review
4.2 Core members of the group are:
North Yorkshire Council: Safeguarding Adults Service Manager (or designated representative)
North Yorkshire Police: Safeguarding Adults Manager
Humber and North Yorkshire Health and Care Partnership/Integrated Care Board (North Yorkshire place): Designated Professional for Safeguarding Adults
4.3 Any professional can make a referral into the S44 panel meeting. There is no referral form as the process is designed to be quick and easy to access. Referrals are made via email to nysab@northyorks.gov.uk, providing basic identifying information and a brief summary of the case. Referrals and cases are tracked on a central spreadsheet by the Review and Improvement Officer within Health and Adult Services.
4.4 The S44 panel provides updates on group activity to the LAR twice per year.
5.1 Any agency representative, local councillors, Members of Parliament or professional MUST refer a case believed to meet the threshold of the criteria identified above in a timely manner, by completing the SAR Referral Form (Appendix 1) and submitting it to the LAR, using the NYSAB email address nysab@northyorks.gov.uk
5.2 A case may be referred by other interested parties including the family. The address for written referrals is included in the Referral Form (Appendix 1).
5.3 The LAR may choose to invite those making a referral in their professional role to present the case to a meeting of LAR. This is to enhance the opportunity to understand fully the context of the case prior to a decision being made.
6.1 On receipt of a referral, the NYSAB Governance Team will (a) acknowledge the notification, (b) quality check the referral, and (c) advise the LAR Chair and NYSAB Independent Chair of the referral. If the mandatory criteria for a SAR appear to be met, approval will be sought from the NYSAB Independent Chair to proceed. Once approval is received, an Initial Chronology will be issued to each partner agency from the NYSAB Governance Team. The purpose of the Initial Chronology is to collect significant information to inform the discussion on whether the SAR criteria are met.
6.2 Where the SAR referral does not indicate the statutory criteria are met, the NYSAB Governance Team may ask the referrer to provide further information. If on receipt of further information, the SAR referral still appears inappropriate, a discussion will be held between representatives from the LAR to decide whether the recommendation should be to proceed, or to decline the referral. The discussion should, at the very least, involve representation from HAS, NY Police, and ICB. The decision will be communicated to the LAR Chair for approval, before the referrer is informed of the decision and the rationale for it.
6.3 In deciding whether a SAR should be conducted, the LAR must first consider whether there is a statutory obligation to undertake a SAR: using the criteria outlined in paragraph 3.1 above. A SAR must be commissioned if there is a statutory requirement to do so.
6.4 A SAR referral will ordinarily be considered at the next available LAR meeting, or within ten working days of all initial chronologies being returned if possible. An extraordinary meeting will be arranged if the next LAR meeting is scheduled beyond this timescale.
6.5 Appropriate scrutiny should be held in relation to the Joint Chronology when determining whether the statutory criteria are met. If the SAR subject is still alive, consideration should be given to their views and experiences when determining whether they have suffered significant harm.
6.6 Consideration should be given to whether other quality assurance and feedback sources (eg audits/complaints) suggest the kind of practice issues in the referral are new, complex or repetitive. If any of the issues and the system conditions indicated in the referral are relevant to the SAB strategic plan, this will be escalated at the earliest opportunity.
6.7 If there is a difference of opinion about whether or not a referral is to be commissioned as a SAR, and a recommendation cannot be reached by consensus, a majority vote will be made and the NYSAB Independent Chair will have the casting vote/decision.
6.8 The recommendation will be forwarded to the NYSAB Independent Chair for ratification. The referrer will be notified of the outcome by a member of the HAS Governance Team using Appendix 3.
6.9 If the LAR considers the threshold is NOT met, but there will be benefit in conducting some form of review, they will consider what type of ‘review’ process will promote effective learning and improvement action to prevent deaths or serious harm occurring in the future. These reviews can provide useful insights into the way organisations are working together to prevent and reduce the abuse and neglect of adults in North Yorkshire. In considering whether there are sufficient lessons to be learned and value in commissioning a Discretionary SAR, LAR will use the guidance shown in Appendix 4.
6.10 The LAR can make the following decisions where the statutory criteria for a SAR are NOT met:
No further action
A review which might include a learning event, either a Discretionary SAR or a short briefing material highlighting key lessons to be learned or a case file audit (learning review), where this is reasonable and proportionate
A management review (within one or more organisations, i.e. a Multi Agency Review or a Single Agency Review)
Rapid Review Process
6.11 The findings of any single or multi-agency review will be shared with the LAR once complete.
6.12 The LAR should also consider whether another review or learning process has already commenced that would identify and share lessons to be learned, or which NYSAB could potentially feed into to avoid duplication (eg Domestic Homicide Review [DHR], Learning Disabilities Mortality Review [LeDeR], Independent Office for Police Conduct [IOPC] investigation or a Serious Incident process). It will be important to provide clarity about any governance issues if other processes are involved. For example, police investigations or an NHS Serious Incident review. If a person has died, the NYSAB Governance Team will contact the Coroner to identify whether an inquest has or will be held.
6.13 Should the referrer challenge the decision of the LAR, the Independent Chair of the NYSAB will respond. The decision can be re-visited if new information has come to light. Any challenge to the decision should be made in writing to the Independent Chair of the NYSAB or NYSAB Governance Team within 28 days of the feedback being received.
6.14 The LAR is responsible for keeping a record of all cases that have been referred and considered for a SAR.
7.1 Once the decision has been made to instigate a SAR, the NYSAB Chair will write to the heads of agencies concerned advising advise them that a SAR will be carried out and asking them to nominate a senior member of staff to support the review process. See Appendix 5. Contact will be made with the Senior Investigating Officer from the relevant police force if criminal proceedings are in process to ensure any review does not undermine police investigations. The SAR may include information already gathered through other investigations (eg Safeguarding Enquiries or Serious Incident Reviews).
7.2 The NYSAB Board Manager will identify and convene an appropriate SAR Panel (SARP) to meet at the earliest opportunity. The SARP will comprise of relevant senior representatives from the key agencies involved in the case. A Chair will also be appointed to lead the SARP.
7.3 In cases where the subject of the review is alive the LAR will seek to gain their consent to share information and complete the SAR as well as explaining the process and hearing their views. Where there are concerns a person is unable to give consent, the principles of the Mental Capacity Act 2005 should be adhered to. If the person does not give consent, legal advice will be sought to help determine whether it is in the public interest to continue. See Appendix 6 for further details about consent. To ensure that the subject is fully supported in this process, consideration will be given to advocacy, either in the form of a suitable family member of friend, or an advocacy service made available via the Local Authority. Where there is involvement of the person and/or their family, in discussion with them, the LAR will agree how they and the interested party will be represented in the report.
7.4 The SARP will create the Terms of Reference. It should reflect the six safeguarding principles set out in the Care Act and NYSAB’s Multi-Agency Safeguarding Policy and Procedures. It should also specify the time period the SAR will cover. The Terms of Reference should be anonymised or consent should be sought if records are to include identifiable information.
7.5 The SARP should nominate and agree an individual within the SAB partnership to communicate with the family whilst the SAR is being undertaken. See Appendix 6 for further guidance. The NYSAB Independent Chair will write to the family or significant others in cases where the subject is no longer alive to inform them of the SAR, explain the process and purpose, and inform them of their point of contact. This should be completed as soon as practically possible. Reasonable and appropriate support and adjustments should be made by NYSAB as required to enable the adult(s), their family and/or representatives to participate in the SAR.
7.6 The SARP should consider who will be consulted as part of the review, and document any reasons why certain family members/friends/others are excluded from contributing.
7.7 An Independent Author (IA) will be commissioned and this will be determined by the methodology employed to undertake the SAR.
7.8 The selection of an IA will include a declaration that the IA does not hold any conflicts of interest in accepting this appointment. Should a conflict of interest arise during the process of the review the IA must declare this at the earliest opportunity to the SAR panel.
7.9 Once the IA has accepted the commission the timescales for completing the SAR will commence. In every case, every effort will be made to complete the review within six months of the commission of the SAR. Where this will be not be possible, the matter will be discussed at the LAR and with the NYSAB chair. Updates will be recorded in the minutes of the LAR meeting. Interested parties, such as the family, will be notified on the progress of the review.
7.10 The SARP will regularly meet during the SAR process to monitor progress and discuss whether any amendments to the Terms of Reference are required.
7.11 Agencies involved in the incident are required under the Care Act 2014 to cooperate with the SAR, and MUST supply all information that may be relevant within the identified timescale.
7.12 Agencies are responsible for ensuring staff are offered appropriate emotional support during the SAR process. This support should be clearly identified and communicated to all staff involved. The death or serious injury of an adult at risk will have an impact on staff and should be acknowledged by the agency. The impact may be felt beyond the individual staff involved to the team, organisation or workplace.
7.13 The SARP should receive and agree the draft report before it is presented to NYSAB via the LAR so that individuals are satisfied that the panel’s analysis and conclusions have been fully and fairly represented.
7.14 The adult(s) and/or family should also be given the opportunity to discuss the SAR report and conclusions, and their experience of the process. Ordinarily, two weeks will be afforded to read the SAR and provide any response. However, extensions will be granted at the discretion of the NYSAB Independent Chair if deemed appropriate to do so.
8.1 Once the LAR has agreed to commission a SAR, a SAR Panel will be convened that must decide on the most appropriate methodology to use. See Appendix 4 for further guidance. This must be appropriate and proportionate to the case under review. The Care Act statutory guidance indicates that, whichever SAR methodology is employed, the following elements should be in place:
– SAR Panel (SARP) – scrutinises information submitted to the review. The panel size should be proportionate to the nature and complexity of the review, but should comprise a minimum of three members in addition to a chair with a level of independence from the case under review
– SARP Chair – independent of the case under review, and with appropriate skills, knowledge and experience (see below)
– Terms of Reference – compiled by the SARP and published as part of the review
– Early discussions with the adult and their family, carers and representative – to agree to what extent and how frequently they will be involved in the SAR, and to manage expectations. This includes access to independent advocacy. See Appendix 6
– Appropriate involvement of professionals and organisations who were working with the adult – to contribute their perspectives without fear of being blamed for actions they took in good faith
– SAR report and recommendations
8.2 The methodology selected must offer the most effective learning and involvement of key staff/family weighed against the cost, resources and length of time required to conduct the review. The methodology should ensure that the principles of Making Safeguarding Personal and the six core adult safeguarding principles are embedded through the review.
8.3 The following should be considered in selecting a SAR methodology:
a) Is the case complex, involving multiple abuse types and/or victims?
b) Is significant public interest in the review anticipated?
c) Is large-scale staff/family involvement wanted/appropriate?
d) Are any criminal proceedings ongoing?
e) Is the type of review being suggested proportionate to the scale and level of complexity of the issues being examined?
f) What methodology is the most effective way to achieve the learning in the quickest timescales?
g) Is a more appreciative approach required to review good practice?
h) Are trained lead reviewers available in-house or nationally for the method selected?
9.1 The SAR report should make visible the systemic risks to single and multi-agency safeguarding work, in order to have practical value in directing improvement actions. It is written with a view to being published. Details of the person are included as judged necessary to illuminate the learning and/or in line with the wishes of the individual or their family.
9.2 The NYSAB must ensure that there is sufficient analysis, scrutiny and evaluation of evidence throughout the SAR process. Analysis assumes a systems approach to safety and organisational reliability. Conclusions are of practical value, evidencing the wider learning identified about routine barriers and enablers to good practice, systemic risks and/or what has facilitated or obstructed change to date.
9.3 The Independent Chair of NYSAB will make appropriate arrangements for the SAR report and other records collected or created as part of the SAR process to be held securely and confidentially for an appropriate period in line with NYSAB’s information sharing agreement, the General Data Protection Regulation (GDPR) and other legal requirements.
9.4 If criminal proceedings remain in place, the report will not be published until any criminal process is concluded on the grounds it may influence a trial; however, any learning can be embedded prior to completion.
10.1 The NYSAB is responsible for ensuring any learning identified within the report has clear recommendations to action change. These recommendations MUST be SMART (Specific, Measurable, Achievable, Relevant and Time bound). Actions are integrated, where ever possible, with the wider strategic aims of the NYSAB.
10.2 The LAR is responsible for identifying an owner for each action and monitoring the actions on the composite action plan. It is the responsibility of NYSAB members to ensure that learning and service change from any safeguarding review is understood, embedded and evidenced with their organisation. NYSAB members will be held accountable for these actions at board meetings. Regular reports on the work of LAR include ‘live’ referrals and reviews and the composite action plan will be presented to the NYSAB by the LAR chair.
10.3 An action plan will be held by the LAR who will meet a minimum of four times a year to review and check progress on each action.
10.4 Any actions relating to areas of work within the remit of NYSAB subgroups will be passed to them. These actions are owned by the relevant subgroup chair who will be expected to submit regular updates to the LAR.
10.5. For recommendations arising from a Single Agency Review, it will be the responsibility of that agency to oversee and implement any actions identified and report back to the LAR.
11.1 Publication should be timely and publicise the key systemic risks identified through the SAR. Publication of the SAR will ordinarily be managed through the NYSAB website, but adapted as necessary for different audiences, including the public. Decisions about what, when, how and for how long to publish and disseminate findings are made with sensitive consideration of the wishes and impact on the person, family and others. A pseudonymised report will usually be published unless the NYSAB Independent Chair agrees there are exceptional circumstances not to do so. In such an event, an Executive Summary may be made available.
11.2 As North Yorkshire Heath and Adult Services are the lead agency for adult safeguarding, media and communication activity about the SAR will be co-ordinated by the North Yorkshire Council’s Communications Unit on behalf of the Board (and in collaboration with the communications teams of the other agencies involved). North Yorkshire Council’s Communications Unit will be briefed as soon as a decision has been made to undertake a SAR and will be kept up to date with the progress of the review by the SAR Panel Chair or nominated officer.
11.3 The NYSAB must include the findings from any SAR in its annual report and include what actions it has taken, or intends to take, in relation to the findings. Where the NYSAB decides not to implement a recommendation then it must state the reason for that decision in the annual report. The SAB maintains a public record of findings, actions and commentary to enable public accountability.
12.1 It is recognised that disputes may arise at any stage during the SAR process, including whether a SAR should be commissioned, how it is commissioned and any aspect of the outcome of the review, including the content of the report. A dispute may arise because of a disagreement or complaint from anyone involved in the SAR process.
12.2 The NYSAB retains ultimate responsibility for the SAR process. Where a dispute arises, it shall be dealt with as follows:
(a) Those responsible for the relevant part of the SAR process shall attempt to resolve the dispute, for example, the LAR before a report is commissioned and SAR panel and/or the IA during the carrying out of a review. Any concern that cannot be resolved with be escalated to the NYSAB Independent Chair for a final decision.
(b) For disputes relating to the report content, the objecting party will provide written representation setting out their concerns to the IA within seven working days of being advised that the final draft report will not be amended.
(c) Where the NYSAB Independent Chair is unable to resolve the dispute, they may recommend to NYSAB that a reference to the dispute, and why it was not possible to resolve, should be included as an addendum to the report.
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