LEARNING FROM SARS: A REPORT FOR THE LONDON …londonadass.org.uk/wp-content/uploads/2014/12/... ·...

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LEARNINGFROMSARS:AREPORTFORTHELONDONSAFEGUARDINGADULTSBOARD

SUZYBRAYEANDMICHAELPRESTON-SHOOT18thJuly2017

Contents

Executivesummary..............................................................................................................2

1.Introduction.....................................................................................................................8

2.Methodology....................................................................................................................9

3.ThenatureoftheSARs...................................................................................................103.1.Casecharacteristics......................................................................................................................103.2.SARcharacteristics.......................................................................................................................123.3.Numberandtypeofrecommendations.......................................................................................17

4.ThecontentoftheSARs..................................................................................................184.1.Domain1:Directpracticewiththeindividual..............................................................................184.2.Domain2:Organisationalfeaturesthatinfluencedhowthepractitionersworked....................274.3.Interprofessionalandinteragencycollaboration.........................................................................364.4.SABsinteragencygovernancerole...............................................................................................42

5.RecommendationsmadeintheSARs..............................................................................465.1Recommendationstoimprovedirectpractice..............................................................................465.2Recommendationstostrengthenorganisationalcontexts...........................................................495.3Recommendationtoimproveinterprofessionalandinteragencycollaboration..........................565.4RecommendationsrelatingtothegovernanceroleoftheSAB....................................................59

6.Integrativediscussion.....................................................................................................626.1SARquality....................................................................................................................................626.2SARcommissioning.......................................................................................................................636.3ThemeswithinthecontentoftheSARs........................................................................................646.4RecommendationsarisingfromtheSARs.....................................................................................67

7.Conclusions....................................................................................................................68

8.Recommendations..........................................................................................................70

References.........................................................................................................................72

Appendix1:Theanalyticframework..................................................................................74

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LEARNINGFROMSARS:AREPORTFORTHELONDONSAFEGUARDINGADULTSBOARDSUZYBRAYEANDMICHAELPRESTON-SHOOT

EXECUTIVESUMMARY:JULY20171. Introduction

1.1. Thisprojectundertookananalysisofthenatureandcontentof27safeguardingadultsreviewscommissionedandcompletedbyLondonSafeguardingAdultsBoardssinceimplementationoftheCareAct2014on1stApril2015,upto30thApril2017.Ofthe30LondonBoards,17submittedreviewsforanalysis,innumbersvaryingbetweenoneandfour.

1.2. Thisprojectformedpartof,andwasoverseenbyaLondonSARTaskandFinishGroup,whoseworkplanalsoincludedtoconsidertheestablishmentofarepositoryofLondonSARs,todevelopqualitymarkersforSARs,todisseminaterelevantlessonsfromLondonSARsandmethodstomeasuretheimpactoflearningfromSARs,andtoestablisharepositoryofSARreviewersandmethodologies.

2. Thenatureofthereviews

2.1. Demographics:Morecasesinvolvedmenthanwomen.Allagegroupswererepresented,withanemphasisonolderoldpeople.Ethnicitywasnotroutinelyrecorded.Justunderhalfthereviewsrelatedtopeopleinsomeformofgroupliving,predominantlyresidentialcare.

2.2. Typeofabuse:Organisationalabusewasthemostcommonformofabuseandneglectpresentinthecasesreviewed,followedbyself-neglectandcombinedformsofabuseandneglect.Three-quartersofthereviewstookplacefollowingthedeathofthepersoninvolved.

2.3. Typeofreview:Almostallthereviewswerestatutoryreviews,i.e.thecircumstancesinwhichtheywerecommissionedmetthegroundssetoutintheCareAct2014underwhichareviewmusttakeplace.MostreportsdidnotstatethesourceoftheSARreferral.

2.4. Methodologies:Themostcommonmethodology,employedinnineofthereviews,wastheuseofchronologiesandindependentmanagementreportssubmittedtoareviewpanelbyagenciesinvolvedwiththeindividual.SixreviewsemployedaSCIEsystemsmodel,withtheremainderemployinghybridorcustom-builtmodels.Theperioduponwhichthereviewsfocusedvariedconsiderably,fromtwoweekstoseveralyears,butinsomecaseswasnotevenspecified.Despitestatutoryguidanceadvicethatleadreviewersshouldbeindependentoftheagenciesinvolved,infourcasesthedegreeofindependencewasquestionable.

2.5. Involvement:Innoneofthecaseswheretheadultwasstillalivedidthereviewindicatewhatconsiderationhadbeengiventotheirinvolvement.Familymemberscontributedtohalfofallthereviews;inmostoftheothercasesparticipationhadbeenofferedanddeclined.

2.6. Lengthofreviewprocess:Inalmosthalfthecases,itwasnotpossibletoidentifyhowlongthereviewprocesshadtaken.Oftherest,onlytwowerecompletedwithintheadvisedtimescaleof6months;othersnoteddelaysduetoparallelprocesses,poorqualityinformation(andinonecaserefusaltoengage)fromparticipatingagencies,orothermethodologicalchallenges.

2.7. Lengthofreport:Thedocumentsmadeavailabletotheprojectforanalysisvariedinlengthbetween2and98pages.Whilemanyboardssubmittedfullreports,somechosetosubmit

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onlyanexecutivesummaryorbriefingnote,limitingthedepthofanalysisthatcouldbeundertakeninthosecases.Thefullreportsrangedbetween12and97pages,themedianbeing33.Theexecutivesummariesrangedbetween2and18pages.Bothbrevityandunduelengthcouldinhibitratherthanaddtothecoherenceoftheunfoldingstoryandanalysis.

2.8. Numberofrecommendations:Thereportscontainedavariablenumberofrecommendations,anythingbetween3and39.In11reviews,allrecommendationsweredirectedattheBoard,whileinothersboththeBoardandspecificagencieswerenamed–themostfrequentlynamedbeingAdultSocialCare.InsomeSARstherecommendationswereframedmorebroadly,directedatunnamedagencies.Recommendationstendedtofocusonmeasuresdesignedtoimprovesingleandmultiagencyperformanceinthelocalcontext,ratherthanuponlegal,politicalandfinancialsystemsthatimpactuponpractice;onlyoneSARcontainedarecommendationaddressedatanationalbody.

2.9. Publication:Onlyeightreportshadsofarbeenpublished,withafurther4executivesummariesinthepublicdomain.Thismaybeareflectionofthetimingoftheprojectratherthananindicationoftheproportionofreportsthatwilleventuallybepublished.

3. Thecontentofthereviews

ThelearningidentifiedintheSARreportsrelatedtofourkeydomainsofthesafeguardingsystem:thequalityofdirectpracticewiththeindividual;organisationalfactorsthatinfluencepractice;interprofessionalandinteragencycollaboration;andtheSAB’sinteragencygovernancerole.

3.1. Thequalityofdirectpracticewiththeindividual:Significantlearningemergedinrelationtoa

rangeofaspectsofdirectpractice:• Mentalcapacity:Missingorpoorlyperformedcapacityassessments,andinsomecasesan

absenceofexplicitbest-interestsdecision-making;• Risk:Absenceorinadequacyofriskassessment,failuretorecognisepersistentand

escalatingrisks,failuretoactcommensuratewithrisk;• Makingsafeguardingpersonal:(a)Lackofpersonalisedcareandfocusonneeds,wishes

andpreferences,insufficientcontact,relianceontheviewofothers;(b)Personalisationprioritisedtotheexclusionofotherconsiderationssuchasrisktoothers;

• Workingwithfamilymembers:failuretoinvolvecarers,and/ortorecognisetheirneeds,absenceofattentiontocomplexfamilydynamics;

• Understandinghistory:lackofcuriosityaboutthemeaningofbehaviour;failuretorecognisekeyfeaturesinlifehistories;

• Challengesofengagement:lackofpersistenceandflexibilityinworkingwithreluctancetoengage,lackoftimetobuildtrustandcontinuity;

• Focusonrelationship.

3.2. Organisationalfactorsthatinfluencehowpractitionerswork:TheSARsidentifiedlearningtooabouttheorganisationsinwhichpracticewaslocated:• Recordsandrecording:keyinformationincasedocumentationabsentorunclear;failure

toconsultrecords;technologyshortcomingsthatcompromisedrecordingpracticeoreasyaccesstoinformation;

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• Safeguardingliteracy:knowledgeandconfidenceofstaff;failuretorecognisesafeguardingconcernsandcumulativepatterns;

• Managementoversightofcases:absenceofsystemstoalertmanagerstoerrorsoromissions;lackofproactivescrutiny;practitioners’failuretoescalate;inadequateresponsetoescalation;

• Staffworkingwithinadequateresources;financialconstraint;servicedemandsaffectingtimeavailable;absenceofspecialistplacements;

• Supervisionandsupport:absenceorinadequacyofsupervision;focusoncasemanagementratherthanreflectivepractice;failuretoensurestaffcompetence,absenceofsupportwithemotionalimpactofthework;

• Organisationalpolicies:missingorunclearpoliciesandguidance;availableguidancenotfollowed;

• Legalliteracy:insufficientorganisationalattentiontoconsideringlegalpowersandduties;• Agencyculture:theimpactofculturesgivinginsufficientprioritytomatterssuchas

accountability,compassionortenancycompliance;short-termcaseturnovermodelofpractice;proceduralisedapproaches;

• Staffinglevels:failuretoensureadequatemixofsuitablyqualifiedstaff;• Marketfeatures:insufficientcontractmonitoring;commissioninggaps.

3.3. Interprofessionalandinteragencypractice:AlmostalltheSARsidentifiedconcernsabout

howagencieshadworkedtogetherinthecasesinquestion:• Servicecoordination:workconductedonmultipleparallellines,lackingcoordinating

leadership;absenceofmultidisciplinaryforumtoestablishsharedownershipandapproach;nooverallriskpicture;absenceofescalationbetweenagencies;

• Communicationandinformation-sharing:crucialinformationnotsharedorcommunicationsnottimely;inadequateprotocols,unclearpathways;

• Sharedrecords:visibilityofkeyrecordstootheragencies/professionals;absenceofsinglerecordsystems;

• Thresholdsforservicescausingdifficultieswithcrossreferral;• Anabsenceofa“thinkfamily”approachtoassessmentofneedsandrisks;• Safeguardingliteracy:failurestoimplementsafeguardingprocedures;inadequate

responsetosafeguardingreferrals;• Legalliteracy:agenciesfailingtoconsidertogetherhowlegalpowersanddutiescouldbe

exercisedinajointstrategy.

3.4. TheSAB’sinteragencygovernancerole:Finally,anumberofSARshighlightedlearningthatrelatedtohowBoardsexercisedtheirgovernancerole:• Training:SARfindingstobeusedtounderpintrainingstrategy;• FactorsaffectingSARquality:

o Valueofusingresearchtounderpinanalysisandlearning;o PooragencyparticipationintheSAR–poorqualityreports,insufficientreflection;

reticencetoengage;o Theneedforprotocolsonparallelprocessessuchasseriousincident

investigations,coroners’enquiries,section42enquiries;

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• Membership:observationsaboutthedebatedvalueofincludingovervieworganisationssuchasCQCandNHSEinSARpanelmembership;

• Impact:somereportshighlighttheimpactonservicedevelopmentforsomeagenciesparticipatingintheSAR;

• Familyinvolvement:considerationbySABsoftheextenttowhichSARfindingsaresharedwithfamilymembers.

4. RecommendationsmadeintheSARs

4.1. SARrecommendationsrelatingtodirectpracticeincludedmeasurestoimproveandenhance:• Person-centred,relationship-basedpractice;• Assessmentandriskassessment;• Whenandhowreviewsareconducted;• Involvementoftheindividual,familymembersandcarers;• Assessmentofmentalcapacityandbestinterestsdecision-making;• Practicerelatingtopressureulcers;• Theneedforspecialistadvicetobeavailabletopractitioners;• Legalliteracyandconsiderationofavailablelegalrules.

4.2. SARrecommendationsrelatingtotheorganisationalcontextforpracticeincludedafocuson:

• Development,disseminationandreviewofguidanceforstaff• Proceduresonassessmentofneedsandrisk• Managementresponsibilities• Staffing:staffinglevels;health&safety;supervision,support,training;• Recordinganddatamanagement;• Commissioningpractice.

4.3. SARrecommendationsrelatingtointerprofessional/interagencyworkingincludedafocuson:

• Informationsharingandcommunication;• Coordinationofcomplex,multiagencycases;• Hospitaladmissionanddischargearrangements;• Professionalrolesandresponsibilities.

4.4. SARrecommendationsrelationtoSABgovernanceincludedafocuson:

• Auditandqualityassurance;• Awarenessraising;• ManagementoftheSARprocess;• ActioninglearningfromtheSAR.

5. Conclusions

5.1. EachSARinthissampledemonstratedauniqueandcomplexpatternofshortcomingsthatimpactedonthecaseunderreview,eachonitsownunlikelytobesignificantindetermininganoutcome,butwhichtakentogetherrepresentedfeaturesthataddeduptoa‘faultline’runningthroughthecase.Typically,weaknessesexistedinalllayersofthesystem,from

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individualinteractionthroughtointeragencygovernance,andbeyondtothebroaderpolicyandeconomiccontext.

5.2. ThuslearningfromSARsisrarelyconfinedtoisolatedpoorpracticeonthepartofthe

practitionersinvolved.Therepetitivenatureofthefindingsandrecommendationswithinthissampleandacrossotherstudiessuggeststhatorganisationalcontextandinteragencycollaborationandgovernancemakeacrucialcontribution.Therearestructural,legal,economicandpolicychallengesthataffectpractitionersandmanagersacrossallagenciesandboroughs.

5.3. ThekeychallengeforSABstherefore,intheirmissiontopreventfuturesimilarpatternsfrom

occurring,iscertainlytobeproactiveinimplementingrecommendationsrelatingtolocalpolicy,proceduresandpractices,butalsotoinvolveregionalandnationalpolicymakersinordertopromotewholesystemcontributiontoservicedevelopment.

6. Recommendationsfromthisstudy

6.1. ThattheLondonSABconsidersestablishingataskandfinishgrouptoupdatethesectiononSARswithintheLondonMulti-AgencySafeguardingAdultsPolicyandProcedures,withthepurposeofexpandingthequalitymarkerstoprovidemoredetailonthemarkersofagoodqualityreport:

6.1.1. Thatthereportcontainsclarityon:

• Sourceofreferral;• Typeofreviewcommissioned;• Rationaleforselectedmethodology;• Periodunderreview;• Timescaleforcompletion;• Reviewerindependence.

6.1.2. Thatthereportrecordskeydemographicdata,includingethnicity;6.1.3. Thatthereportconcludeswithclear,specificandactionablerecommendationswith

clarityontheagenciestowhichtheyaredirected;6.1.4. ThatSABscomplywithstatutoryguidancerequirementoninclusionofSARdetailsin

annualreportsthatarepublishedinatimelyfashion.

6.2. ThattheLondonSABconsidersreviewingandupdatingtheLondonMulti-AgencySafeguardingAdultsPolicyandProcedureswithrespecttoSARs,therebyrecommendingtoSABsthatthey:

6.2.1. MonitorSARreferralsandtheiroutcomestocheckthatSARsreferredandcommissioned

overtimearebroadlyrepresentativeofthepatternofreportedincidenceofformsabuseandneglectinthelocality;

6.2.2. Reviewsafeguardingproceduresandguidanceinthelightoflearningfromthisreport;6.2.3. ReviewSARguidanceinthelightofthelearningfromthisreport.

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6.3. ThattheLondonSABconsidersdisseminationofthisreportto:

6.3.1. TheDepartmentofHealthtoinformpolicyregardingSARs;6.3.2. NationalbodiesrepresentingSABstatutoryandotherpartnerstopromptdialogueabout

policyregardingSARs;6.3.3. Facilitatediscussionandthedevelopmentofguidanceregarding:

• Thresholdsforcommissioningdifferenttypesofreview;• Indicationsforthechoiceofavailablemethodologies;• Managementofparallelprocesses;• TheinterfacewithSCRsandDHRswhenthecriteriawouldbemetforsuch

reviewsalongsidethoseforaSAR;

6.4. ThattheLondonSABconsidersfurtherstudiesregarding:

6.4.1. HowthresholdsareforcommissioningSARsarebeinginterpreted;6.4.2. TheimpactandoutcomesofSARscommissionedandcompletedbySABsinLondon;6.4.3. Theadvantagesandlimitationsofdifferentmethodologiesinthelightoflearningfrom

thisreport;

6.5. ThattheLondonSABconsiderswhatsupportitcanprovidetoSABsandtheirstatutorypartnersregardingtheprocessofcommissioning,completingandimplementingthefindingsofSARs,withparticularreferenceto:6.5.1.Promotingtransparencyinthechoiceofmethodology;6.5.2.Facilitatingtransparencyofinformation-sharingandcandidanalysisinIMRs,paneldiscussionsandlearningevents,inordertopromoteserviceandpracticedevelopment;6.5.3Qualityassuranceoffinalreports.

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LEARNINGFROMSARS:AREPORTFORTHELONDONSAFEGUARDINGADULTSBOARDSUZYBRAYEANDMICHAELPRESTON-SHOOTJUNE20171. INTRODUCTION

1.1. ThisreportpresentsananalysisofSafeguardingAdultReviews(SARs)undertakenbyLondon

SafeguardingAdultsBoards(SABs)sinceimplementationoftheCareAct2014on1stApril2015.Itdrawsonpublishedandunpublishedreviewsupto30thApril2017toidentifycommonthemesandlessonsthathaveimplicationsbeyondthelocalsystem.Thesethemesandlessonsrelatetocommissioningreviews,thequalityofreportsandthereviewprocessitself,andalsotothefindingsofinvestigationsintoindividualcasesandtherecommendationsthatemerge.

1.2. ThereportdrawsonpreviousauditsofLondonreviews(Bestjan,2012;Brusch,2016)inorder

toprovideacomparativedevelopmentalperspective,namelyananalysisofthedegreetowhichthemesandlessonsemergingfromreviewscommissionedafterimplementationoftheCareAct2014aresimilartoordifferentfromwhatearlierreviewshaveuncovered.Inanalysingthereviews,thereportconsiderstheapplicabilityforSafeguardingAdultsBoards(SABs)oftheWoodReport’s(2016)critiqueofseriouscasereviews(SCRs)commissionedbyLocalSafeguardingChildrenBoards(LSCBs),namelytherepetitivenatureoffindingsandrecommendations,andthefailuretoinvolvepractitioners.Whereactionplansarealsoavailable,thereportaddressesanotherofWood’scriticisms,namelythefailuretolearnlessons.

1.3. Theanalysisprovidesanopportunitytocritiquethevariousmethodologiesthatareavailable

forSARs,toanalysehowSABsarerespondingtothestatutoryguidance(DH,2016)relatingtothecommissioningofreviewsanddisseminationoftheirfindings,andtodevelopkeywordsthatcouldbeusedinanysubsequentdevelopmentofaLondonSARrepository.Detailedconsiderationofhoweachreportisconstructed,cross-referencedtoavailablestandardsforSCRsandSARs(SCIEandNSPCC,2016;LondonADASS,2017),alsoenablesconsiderationofSARquality,thusansweringanotherofWood’schallenges(2016),namelythatthereisnodefinitionofwhataqualityreviewlookslike.

1.4. Thisprojectformedpartof,andwasoverseenbyaLondonSARTaskandFinishGroup,whose

workplanalsoincludedtoconsidertheestablishmentofarepositoryofLondonSARs,todevelopqualitymarkersforSARs,todisseminaterelevantlessonsfromLondonSARsandmethodstomeasuretheimpactoflearningfromSARs,andtoestablisharepositoryofSARreviewersandmethodologies.

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2. METHODOLOGY

2.1. LondonADASSapproachedeachLondonSABtoidentifyhowmanySARshadbeencommissionedsinceimplementationoftheCareAct2014on1stApril2015and,ofthese,howmanyhadbeencompletedandwerethereforepotentiallyavailableforanalysis.Thisprocessidentifiedapotentialsampleof30SARs.ReassurancesweregiventhatSABsandSARswouldnotbeindividuallyidentified,thisguaranteeofanonymityandconfidentialitybeingespeciallyimportantinrelationtounpublishedreviews.

2.2. Afinalsampleof27SARswasobtainedforanalysis.NotallSABsreleasedthecompleteSAR,

somepreferringtosubmiteitheranexecutivesummaryoracondensedbriefingofthecaseandthelearningextractedfromit.Thisvariabilitywithinthesamplehasimplicationsforthedetailanddepthofanalysisinsomecases.Althoughallsubmittedmaterialenabledananalysisofkeythemesandrecommendations,thevariabilitymadeitmoredifficulttocommentfullyonthereviewprocessfromcommissioningthroughtodissemination,andonthequalityoftheSARs.Insubmittingtheirreports,SABswerenotaskedtocommentonhowthelearningfromreviewshadbeentakenforward,althoughsomeSARseitherincludedanactionplanoridentifiedinitialimpactsonpolicyandpractice.Thislimitsananalysisofhowchangehasbeenmanagedandembeddedfollowingcompletionofreviews.

2.3. Theanalyticalmethoddrewonatemplateusedpreviouslywhenderivinglearningfrom

reviewsfeaturingself-neglect(Braye,OrrandPreston-Shoot,2015).Itexplored:

(a) ThenatureoftheSARs,focusingonfourlayers:• Casecharacteristics(suchasgender,ethnicity,triggerforreview);• SARcharacteristics(suchasmethodology,typeofabuse/neglect,length,whether

publishedandnumberofrecommendations);• Numberandtypeofrecommendations;• Themeswithinrecommendations;

(b) Thekeythemeswithinthelearningthatemergesfromanalysisofthecontentofthe

SARs,focusingonfourdomainsthatenablecross-casesystemicanalysis:• Directpracticewiththeindividualadult;• Organisationalfactorsthatinfluencedhowthepractitionersworked;• Howpractitionersandagenciesworkedtogether;• TheSAB’sinteragencygovernancerole.

Thefullanalyticframework,combiningthecategoriesthatwereanticipatedasaresultofthepreviousresearchandthosethatemergedfromreadingoftheSARs,maybefoundatAppendix1.Manyofthecategoriescouldformthebasisforsearchtermsifandwhenarepositoryisestablished.

2.4. Section3ofthisreportpresentsfindingsonthenatureoftheSARs–thecasecharacteristics,

theSARcharacteristics,andthetypeofrecommendations(therecommendationthemesarecoveredinalatersection).Section4considersthecontentoftheSARs,presentingthe

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learningaboutfourdomainsoftheadultsafeguardingsystem–directpractice,organisationalcontext,interagencycollaborationandSABgovernance.Section5presentsthethemesobservableintheSARrecommendations,identifyinghowtheseemergefromthelearningaboutthefourdomainsoftheadultsafeguardingsystem.Section6engagesinanintegrativediscussionofthefindings,beforeashortconclusioninSection7andrecommendationsinSection8.

2.5. Inaddition,ontwooccasionsoneoftheauthorsofthisreportattendedameetingofthe

networkofindependentchairsofLondonSABs.Onthefirstoccasion,atthestartofproject,thegroupdiscussedtheirexperienceandperceptionsoftheSARcommissioningprocess,andofthechallengesthatariseduringthereviewprocess.Onthesecondoccasion,attheendoftheproject,thegroupheardashortpresentationonheadlinefindingsfromtheanalysisoftheSARs,andreflectedupontheirimplicationsforfutureSARactivity.Whererelevant,theirviewsareincludedintheintegrativediscussioninSection6ofthisreport.

3. THENATUREOFTHESARsThefirstformofanalysisundertakenwasofthelearningthatemergedaboutthenatureoftheSARsincludedwithinthissample.3.1. CaseCharacteristics1

3.1.1. Genderandage:Asinsomepreviousstudies(Braye,OrrandPreston-Shoot,2015),thegenderdividehasrevealedaslightpreponderanceofmen.Asinotherstudies(Bestjan,2012;Braye,OrrandPreston-Shoot,2015),olderpeopleandespeciallyolderoldpeopleareheavilyrepresented.

Gender(n=29)Male 17Female 11Notspecified 1

Age(n=29)18-39 440-59 260-79 680+ 8Notspecified 9

3.1.2. Ethnicity:Asalsofoundinotherstudies(ManthorpeandMartineau,2011;Braye,OrrandPreston-Shoot,2015;Brusch,2016),ethnicityisnotroutinelyrecorded.Bestjan(2012)observedthatconcerntoprotectanindividual’sidentitymightbethedriverhere.However,thefactthat

1Insomeofthetablesbelow,n=29becauseintwoofthe27SARstwoadultsarethefocusofconcern.

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otherindividualcharacteristics,suchasageandgender,aremorecommonlyreportedwouldsuggestotherfactorsatplayhereandprovidescauseforconcern.

Ethnicity(n=29)WhiteUK 6Guyanan 1BlackBritish/Caribbean 1Unspecified 21

3.1.3. Livingsituation:Bestjan(2012)inhersmallersamplefoundthattwo-thirdsofadultswerelivinginthecommunity.Thepercentageislowerat57%inthisstudy.Thenumberofcasesinvolvinggrouplivingaccommodationraisesquestionsaboutthequalityofcareandsupportprovision.

Household(n=29)Livingalone 8Livingwithpartner 1Livingwithpartnerandchildren 1Livingwithchild(ren) 4Livingwithfriend 3Groupliving 12

Accommodation(n=29)Sociallandlord 7Sociallandlord(sheltered) 5Carehome 10Other2 2Notspecified 5

3.1.4. Typesofabuseandneglect:Organisationalabuse3featuresprominentlywhentypesofabuseorneglectareconsidered,asitdoesinanotherdatabaseofreviewswhere58%ofthesample(n=74)featuredconcernsaboutpracticeincarehomesorhospitals(HullSafeguardingAdultsPartnershipBoard,2014).Sotoodoesself-neglect,reinforcingfindings(Braye,OrrandPreston-Shoot,2014)aboutthecomplexitiesandchallengesofthisaspectofadultsafeguarding.

Significantalsoarethetypesofabuseandneglectnotrepresentedinthissample.Noreviewsinvolvingdomesticabuseweresubmitted,possiblyexplainedbythestatutorydutytoundertakeDomesticHomicideReviews(DomesticViolence,CrimeandVictimsAct2004).NoSARsfocusedonmodernslavery,raisingquestionsabouthoweffectivelyadultsafeguardingsystemsareidentifyingthisformofabuse.

2Onepersonwaslivingintemporaryaccommodation.Onepersonwaslivinginrentedaccommodationbutitwasunclearwhetherthiswasprivatelyrentedorsocialhousing.3Statutoryguidance(DH,2016)definesthisasincludingneglectandpoorcarepracticewithinacaresettingorinrelationtocareprovidedwithintheperson’shome;oneoffincidentsoron-goingill-treatment.

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Typeofabuseandneglect(n=27)Physicalabuse 1Sexualabuse 1Financial/materialabuse 1Neglect/omission 1Organisationalabuse 9Self-neglect 7Combined 54Other 25

3.1.5. Outcomeoftheabuseorneglect:Bestjan(2012)identifiedthat,inhersample,95%ofreviewshadbeencommissionedfollowingthedeathofanadult.ThiscontrastssignificantlywithManthorpeandMartineau’sfindings(2011)whereonly59%ofreviewsfollowedafatalityandtheaforementioneddatabasewhere55%ofcasesinvolvedadeath(HullSafeguardingAdultsPartnershipBoard,2014).ThepercentageinthissampleofreviewscommissionedsinceimplementationoftheCareAct2014(76%),whilstmidwaybetweenpreviousfindings,invitesthesamequestionabouttheoperationofthresholds.Bestjan(2012)advisedthatSABsshouldreassurethemselvesthatcasesnotinvolvingfatalitieswerebeingreviewedaccordingtothethenprevailingADASSguidancesoastoprovideopportunitiesforlearning.ShealsonotedthatfirefatalitieshadbeentreatedbothasanSCRandasa“lesser”multi-agencyreview,indicatinginconsistentdecision-makingincommissioningreviews.Thecurrentsamplesimilarlyraisesaquestionabouthowincidentsofabuseandneglectthatdonotresultinafatalitybutnonethelessmightmeetthethresholdcriteria(DH,2016)arebeingreviewed.

Outcomeofabuseorneglect(n=29)Deceased 22Financial/materialloss 1Injury 1Movedtoacarehome 2Notspecified 3

3.2. SARCharacteristics

3.2.1. Referralsource:Ofthe27reports,only7specifiedtheoriginofthereferral.Fiveoriginatedthroughreferralsforsection42CareAct2014enquiries,threeemanatingfromadultsocialcare,onefromtheLondonAmbulanceServiceandonefromaHospitalNHSTrust.OnewasreferredbytheCourtofProtectionandonearosefromasafeguardingcaseconference.Theremaining20reviewsdidnotspecifytheoriginofthereferral.Oneofthecriteriaforaqualityreviewarguablyistransparencyaboutthereferralitselfandsubsequentdecision-making(SCIE/NSPCC,2016;LondonADASS,2017).WhilstthereviewscommonlystatedthestatutorycriteriafordecidingwhethertocommissionaSAR,thelackofinformationaboutthesourceofthereferralandthe

4Threecasesinvolvedacombinationofself-neglectandneglectbyothers.Onecaseinvolvedbothneglect/omissionandfinancialabuse.5Onecasefocusedonanincidentinacarehomebetweentworesidents,asaresultofwhichonedied.Onecasefocusedonaperson’ssuicide.

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informationprovidedattheoutsetmakesitdifficulttoevaluatewhethersufficientinformationwasavailabletodeterminewhetheraSARwasjustifiedandthenatureofthereviewrequired.

3.2.2. Typeofreview:TwentytwoSARsweredescribedasstatutoryreviews,meaningthatthecriteriaoutlinedinthestatutoryguidance(DH,2016)forwhenSABsmustarrangeaSARwerefullymet.Onewasdescribedasanon-statutorySARandoneasalearningreview,boththeresultofaSABexercisingitsdiscretiontocommissionaSARinvolvinganadultwithcareandsupportneeds(DH,2016).Thetypeofreviewwasnotspecifiedinthreereports.Giventhatthecriteriaforaqualityreviewincludetransparencyaboutthedecision-makingprocessandclarityofpurpose(SCIE/NSPCC,2016;LondonADASS,2017),someSARscouldbeclearerabouttherationaleforthetypeofreviewcommissioned.

3.2.3. Reviewmethodology:TherationaleforthechosenmethodologywasnotalwaysclearlystatedwhenreportingintheSARonthecommissioningprocess.Availablequalitycriteria(SCIE/NSPCC,2016;LondonADASS,2017)recommendinputfromreviewersandBoardmembersontheapproachtobeused,whichmayhavehappenedbutisnotreportedoninthereviews.Someopaquenessalsoremainsabouttheprecisemethodologythatwasfollowed.Ashasalsobeennoted(Preston-Shoot,2016;2017)increasinglydiversemethodologiesarebeingused,althoughthetraditionalapproachofindependentmanagementreviews,combinedchronologyandpaneldeliberationstillappearsmorecommonthanthoseinvolvinglearningeventsandinterviews.Thestatutoryguidance(DH,2016)isclearthatnoonemodelwillbeapplicableforallcasesbutmoreworkisrequiredonindicatingtherationaleforchoosingaparticularapproachinordertoachieveunderstanding,promoteeffectivelearningandarriveatrecommendationsforchangeandimprovementaction.

Methodology(n=27)IMRs+Chronology 9IMRsonly 2SCIESystemsModel6 6SILP7 1HybridModelcombiningelementsoftheabove 2Other8 5Notspecified 2

Reportscommonlywereclearonhowthereviewprocesswasmanaged,forexamplethroughthecreationofapanel,independentlychaired,thatstrivestomanagetheprocessthroughtoatimelyconclusion.SARscommonlylistedtheagenciescontributingtothereviewand

6SeeFish,S.,Munro,E.andBairstow,S.(2009)LearningTogethertoSafeguardChildren:DevelopingaMulti-AgencySystemsApproachforCaseReviews.London:SocialCareInstituteforExcellence.7SeeClawson,R.andKitson,D.(2013)‘Significantincidentlearningprocess(SILP)–theexperienceoffacilitatingandevaluatingtheprocessinadultsafeguarding.’JournalofAdultProtection,15(5),237-245.8Onereviewusedrootcauseanalysisandaworkshop;twogatheredinformationfromsection42documentation,agencyrecordsandinterviews;oneisdescribedasamulti-agencyreviewinvolvingalearningeventandIMRs;onereportwascompiledfromchronologies,agencyrecordsandmeetings.

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membershipofthegroupresponsibleformanagingtheprocess.Thus,onereviewnotestheactiveinvolvementofaCoroner,anotherthecontributionofstafffromneighbouringauthoritieswherethereviewfocusedonacompanyrunningcarehomes.Inrespectofregulatedservices,panelsappeartohaveadopteddiverseapproachestotheinvolvementoftheCareQualityCommission(CQC),sometimesinvolvingCQConthepanelfromtheoutset.Onereport,whereCQChadnotbeenincludedinthereviewprocessitself,recommendedtheirinclusionincasesoforganisationalabuse.

Thestatutoryguidanceadvisesthatreviewsshouldbeledbyindividualswhoareindependentofthecaseandoftheorganisationsinvolved.Nonetheless,infourreviewsthedegreeofindependencebroughtbythereportauthorisquestionable,raisingquestionsofcompliancewithstatutoryguidance(DH2016).

3.2.4. Familyparticipation:Statutoryguidance(DH,2016)advisesthatfamiliesshouldbeinvitedtocontributetoreviews.Availablestandardsforqualityreviews(SCIE/NSPCC,2016;LondonADASS,2017)alsorecommendfamilyinvolvementwhenconsiderationisbeinggiventowhetherornottocommissionaSAR,thetermsofreferenceandtheapproachtogatheringinformation.Thishelpstoensurethatreviewsareinformedbytheirknowledgeandunderstanding;italsohelpstomanagetheirexpectations.Giventhehighpercentageoffatalitiesamongstthesample,themajorityofreportscannotcommentontheinvolvementoftheadultatrisk.However,infivecaseswheretheadultatriskwasstillalive,thereviewsdonotspecifywhatconsiderationwasgiventotheirinvolvement.Familymemberscontributedtofourteenreviews,althoughitappearsthatthiswassubsequenttothesettingoftermsofreference.However,inelevencasesinvolvementwasofferedanddeclined.Inthreecasesthereviewdoesnotspecifywhetherfamilieswereapproachedandwhattheirresponsemighthavebeentoinvolvement.

Notallfamilymembers,whetherornottheyactivelyparticipatedinaSAR,werecriticalof,orconcernedabout,thelevelofcareandsupportprovidedtotheirrelatives.Somefamilymembersparticipatedexplicitlyinordertocontributetolearningandimprovementaction,afindingalsonotedinastudyoffamilyinvolvementinSCRs(Morris,BrandonandTudor,2015).However,whilstnotalwaysexplicitlystated,familymembersmayhavedeclinedinvolvementbecausetheywereseekingseparateavenuestoholdindividualsand/ororganisationstoaccount,whichisnotthestatedpurposeofaSAR(DH,2016).

3.2.5. Lengthofthereviewprocess:Statutoryguidance(DH,2016)advisesthatSABsshouldaimforcompletionofaSARwithinsixmonthsofinitiatingitunlesstherearegoodreasonsforalongerperiodbeingrequired.Astheguidancenotes,thereviewprocessmighthavetoaccommodateparallelprocesses,suchaspoliceorcoronialinvestigations.Tworeviewscommentonsuchparallelprocessesashavingdelayedeithercommissioningorcompletion.However,SABshaveclearlyencounteredotherchallenges,includingthepoorstandardofIMRs,whichrequiredfurtherattemptstoobtaininformationandadequateanalysisofdecision-making,difficultiesinarrangingmeetingsorinterviews,andthenon-availabilityofstaffinvolvedinthecase.Alsooccasionallyapparentis

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defensivenessamongsttheagenciesinvolved,areticencetolearnlessonsoroffertransparency,amountinginonecasetoanagency’srefusaltoengageatall,aphenomenononwhichWood(2016)commentswithrespecttoSCRscommissionedbyLSCBs.Cross-boundarychallengesarereferredtoinoneSAR.Morepositively,anumberofSARscommentonactionsalreadyhavingbeentakentoaddressurgentissueshighlightedbythereviewprocess.

Difficultieswereoccasionallynotedregardingmethodology.Acoupleofreviewsweredelayedbyeitherthenon-availabilityoftheoverviewreportwriterortheirreplacementwithasecondreviewer.OnereportnoteddisagreementoverthevalueoftheSCIEmethodologythathadbeenused,withsomeagencieswantingclearrecommendationsforactionratherthanthefurtherquestionsthatformedtheoutcomeofthereviewprocess.Twoothersidentifylackoffamiliaritywiththemethodologybeingusedasacontributoryfactortodelay.Thishighlightstheimportanceofclarityfromtheoutsetaboutdesiredoutcomesandtheexpertiseandapproachnecessary.

NoteworthytooisthenumberofreportswherethelengthoftheSARprocessiseithernotspecifiedorisunclear,inthelattercaseusuallybecausethestart-dateisnotgiven.Greaterattentionisthereforeneededwithrespecttoqualitystandards(SCIE/NSPCC,2016;LondonADASS,2017),whichfocusonthetimelinessofdecision-makingandtheeffectivemanagementoftheprocessofsettingupandrunningareview.

Timelinessofreporting(n=27)Completedwithinsixmonths 2Betweensixmonthsandoneyear 8Longerthanoneyear 5Unclear 7Notspecified 5

3.2.6. Lengthofperiodreviewed:Asmightbeexpected,therewasconsiderablevariationinthetimeperiodunderconsideration,rangingfromaweektoseveralyears.Ofconcern,however,inlightofqualitystandardsrelatingtotransparencyandclarityofpurpose,insixreportsitwasnotpossibletoascertaintheperiodunderreview.

3.2.7. Lengthofreport:Thesamplerangesacrossfullreports,executivesummariesandbriefingnotes,withtheshortestdocumentbeing2pagesandthelongest98.Drawingagainonqualitystandards(SCIE/NSPCC,2016;LondonADASS,2017),forlearningtobeeffectiveingeneratingandsustainingserviceandpolicydevelopment,andpracticeimprovement,analysisshouldbetransparentandrigorous,illuminatingchallengesandconstraintswhenseekingtosafeguardadults,andcomparingresearchevidenceonbestpracticewiththeorganisationalandpracticeenvironmentbeingreviewed.Reportsshouldbeanalyticalratherthandescriptive,withconclusionsandrecommendationsclearlyemanatingfromandlinkedtofindings.

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Lengthofreport(n=27)1-10pages 411-20pages 321-30pages 831-40pages 441-49pages 250+pages 6

Indeed,somereportswereabletopresentananalysisthatansweredthequestions“why?”Othersacknowledgedthedifficultyinsodoing,forexamplewhenstaffinvolvedhadlefttheagenciesinvolved,organisationalrecordsweredescriptiveand/orincomplete,orpractitionerswerenotinterviewedaspartoftheprocessofinformation-gathering.Brevityorunduelengthcouldinhibitratherthanaddtothecoherenceoftheunfoldingstoryandanalysis.Somepublishedreportscontainedtypographicaland/orgrammaticalerrors.

3.2.8. Publication:Bestjan(2012)foundthatthevastmajorityofreviewsinhersamplewerenotaccessibleonwebsitesorpublished.Hasthepicturechanged?Thestatutoryguidance(DH,2016)givesdiscretiontoSABstodeterminewhethertopublishcompletedSARs.Giventhetimeperiodforthisproject-reviewscommissionedonorafter1stApril2015andcompletedbytheendofApril2017-itisnotsurprisingthatjustoverhalfhadnotbeenpublished.ThisfiguremayreduceasSABscompletetheirdecision-makingabouthowfindingsaretobedisseminatedandpolicyorpracticeissuesaddressed.

Publication(n=27)Wholereport 8Executivesummary 4None 15

Statutoryguidanceisclear,however,thatSABsmustincludeSARfindingsinannualreportsandcommentontheactionscompletedortobeundertakentoimplementlessonslearned.Again,thetimescaleofthisprojecthasmeantthatSABswouldbeexpectedtocommentoncompletedreviewsintheir2016/17annualreports,whichwillnotappearuntillaterin2017.However,itisnoteworthythatinfourinstanceswhereitwouldbeexpectedtoreaddetailsaboutacompletedSARinanannualreport,noreferencewasfound.Similarly,notallannualreportsreferencereviewsthathavebeencommissionedbutnotyetcompleted.Finally,notallSABshaveuploadedontotheirwebpagestheir2015/16annualreport.AllthisraisesquestionsaboutthedegreetowhichSABsareCareActcompliantandthedegreetowhichlearningisdisseminatedandcanbeshown,throughapublishedanddetailedactionplan,tobegeneratingortohaveresultedineffectivechange.

Annualreportinclusion(n=27)Toosoon 15Noreference 4Details,recommendationsandactionplangiven 3Detailsandrecommendationsgiven 5

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3.3. Numberandtypeofrecommendations

3.3.1. IthasbeensuggestedthatincreasinglyrecommendationsarebeingdirectedtotheSABalone,allocatingtoittheresponsibilityforensuringanactionplanisimplemented,withpolicyandpracticereflectingfullytheconclusionsofthereview(Preston-Shoot,2017).Inthissample,11SARsaddressedallrecommendationstotheSAB,numberingintotal126,witharangefrom5to28.Onereviewinthissub-samplealsolistedrecommendationsofferedbypractitionersandmanagersduringtheirparticipationinreflectiveconversationsandlearningevents.

3.3.2. InelevenotherSARs,SABswerealsogivennamedsoleresponsibilityfortakingforward

33recommendations,ranginginnumberfrom1to7,aspartofaseriesofrecommendationswhereotheragencieswerealsogivenresponsibilityforserviceimprovement.InonefurthercaseaSABwasrecommendedtoworkwithnamedotherpartnerstotakeforward2recommendations.

3.3.3. Reflectingthatsafeguardingiseveryone’sbusiness,therangeofagenciestowhichthe

SARreportsgiveresponsibilityforrecommendationsiswide.Itshouldbenotedthatrecommendationsaddressedtoaparticularagencycouldcontainanumberofseparateactions.Thus,inoneSAR,thereweresixelementstotheonerecommendationforGPsandtenactionswithrespecttotheonerecommendationforcommunitynursing.Thesinglerecommendationsforadultsocialcare,housingandcareagencycontainedsix,twoandthreeelementsrespectively.Thisindicatesthescaleofthechangebeingsought.

Agency No.of

SARsNo.ofrecommendations

CCG 6 7AdultSocialCare 10 21Communityhealthcare 4 5HospitalTrusts 6 12NHSTrusts(combined) 2 5Localauthority(OT,QA,SAT,Commissioning) 8 16Carehomes 2 7Careagency 1 1Housing 5 10GPs 3 3LondonAmbulanceService 2 2Police 2 3FireandRescue 1 1MASH 1 2Hospice 1 1Allagencies 7 30

3.3.4. FourSARscontainedatotalof25recommendationsforunnamedagencies,witharange

between1and18.Aspreviouslyobserved(Brayeetal.,2015;Preston-Shoot,2017),this

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potentiallycomplicatestheconstructionofactionplansandthesubsequentevaluationoftheimpactoflearning.

3.3.5. IthasbeenarguedthatSARshavebeeninsufficientlysystemicinthatthenationallegal

andpolicycontexthasbeenfrequentlyignored,withthefocusonhowsingleandmulti-agencysystemshaveperformedinalocalcontext(Preston-Shoot,2016).When,forexample,mentalcapacityandinformation-sharingcomprisetwosignificantcriticalthemestoemergefromSARs,andtheimpactoffinancialausterityacontextthatinfluencesthresholdsandmanagementofworkloads,itissurprisingthattheimpactoflegalandpoliticalsystemsisnotroutinelypartoftheanalysis,withrecommendationstocentralgovernment.Onlyonereviewcontainedanationalrecommendation.

4. THECONTENTOFTHESARS

ThesecondformofanalysisundertakenwasofthelearningthatemergedfromthecontentoftheSARsincludedwithinthissample.Thefocuswasuponfourdomainsthatprovidetheframeworkforasystemicoverviewofthatlearning:directpracticewiththeindividualadult;organisationalfactorsthatinfluencedhowpractitionersworked;interprofessionalandinteragencypractice;andSABs’interagencygovernancerole.

4.1. Domain1:Directpracticewiththeindividual

Thethemesfoundwithinthedirectpracticedomainwere:mentalcapacity,riskassessment,makingsafeguardingpersonal,workwithfamilymembers,theimportanceofunderstandingtheindividual’shistoryandrelationships,challengesofengagement,relationship-basedpractice.ThereemergedalsosomeimportantaspectsofdirectpracticethatwerepresentonlyinsingleSARs,andalsoanotableabsenceoffocusonethnicity.

4.1.1. Mentalcapacity:Twentyoneofthe27reportscommentedonmentalcapacity,whichrepresentsthereforethemostfrequentlyrepresentedlearningaboutdirectpractice.Despitetheoccasionalcommentinonecasethatmentalcapacityhadbeenwelladdressedandbestinterestsdecisionsappropriatelyimplemented,muchofthelearningintheSARsisaboutmissingorpoorlyperformedcapacityassessment,insufficientscepticismandrespectfulchallengeofdecision-makingandpossibleconsequences,andinsomecasesaboutanabsenceofbestinterestsdecision-making.

TenSARsexplicitlystatethatassessmentswerenotinitiatedorcompletedatappropriatepoints;theiromissionwasnotedinawiderangeofdecisionsandbyawiderangeofpractitionersindifferentsituations,includingadmissiontohospitalornursingcare,dischargehome,consenttocareandtreatment-insomecasesquitesignificantdecisionsonmattersthatsubsequentlycontributedtothefinaloutcomeofthecase.Insomecases,therewascollectiveomissionofcapacityassessmentbyallthepractitionersinvolvedinacase.Onereportspecificallycommentsthatcapacityassessmentaboutaveryspecificfeatureofanindividual’sdailylivingskillscouldhaveprovidedarobustframeworkforsettinginplacemoreeffectiveriskmanagementoftheveryactionsthatcausedhisdeath.InonecasetheSAR

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foundmentionofbestinterestsinterventionwithoutevidencethatcapacityhadbeenformallyassessed.

Theabsenceofrepeatcapacityassessmentswasafurtherfeaturenoted.Intwocases,oncetheindividualhadbeenfound(orassumedtohave)capacity,deteriorationintheirhealthand/orhomesituationdidnottriggerreviewoftheircapacity.Equally,inthecontextofanestablishedfindingthatanindividuallackedcapacityoverhisfinancialaffairs,achangeoflivingsituationdidnottriggerafurthercapacityassessmentduringwhichthearrangementsformanaginghisfinancescouldhavebeenreviewed;initsabsence,alongchainofeventsdeprivedhimofhisincomeforalengthyperiod,withresultantimpactonhisactivitiesandwellbeing.

ThreeSARscommentthatcapacityassessmentswereinadequatelyrecorded,orrecordedwithoutsufficientdetailforthereasoningbehindthemtobetransparent.Sevenreportscommentontheimpactofpractitionersmakinganinsufficientlytestedpresumptionofcapacity,sometimesinrelationtoquitesignificantdecisionsonmedicaltreatmentoronself-care,whichmeantthatthepossibleneedforbestinterestsdecisionswasnotconsidered.TwoSARscommentthatpractitionersmayhavemisunderstoodtheconceptofself-determinationand,becausecapacitywasassumed,missedopportunitiestobalancechoiceandindependencewiththeneedforprotectionandsafety.AndafurtherSARnotessimilarlythatanemphasisonautonomyledtoafailuretoconsiderthebalancebetweenchoiceandrisk.Anotherpointstothepresumptionofcapacityleadingtoafailuretomakeaformalassessment.Andinonecase,theknowledgethatanindividualwasabletodriveledtoanassumptionthattheyhadcapacityinotherareasoftheirlife,despitediagnosesthatcouldhaveimpliedtheneedforthattobetested.

InsevenSARs,thelearningwasaboutcapacityassessmentsthatdidnottakeaccountofthefullcomplexityofthesituation,orofthefactorsinfluencinganindividual’sdecision-making.Inoneexample,theimpactofincreasingphysicalpainontheabilitytounderstand,retain,useandweighrelevantinformationwasnottakenintoaccount.Inanother,cognitiveimpairmentthatwouldhaveinterferedwithanindividual’sunderstandingofriskswasnotidentified.Inafurthercase,itemerged(buttoolatetopreventtheindividual’sdeath)thatherrefusalofcarehadresultedfromcoercionandcontrolbyarelative.OneSARnotesthatwhattheindividualstatedwasacceptedatfacevalue,notchallengedandnottriangulatedwithotherevidenceorinformationthatmighthaveindicatedadifferentpicture.Andinanother,thereviewobservesthatthepossiblelong-termimpactofknownalcoholconsumptionwasnottakenintoaccount.Inonecaseinwhichsomepartsoftheprofessionalsystemheldinformationaboutimpairedbrainfunctionthatwouldhaveinterferedwiththeindividual’sdecision-making,lackofcommunicationmeantthatthepractitionerundertakingacapacityassessmentinasituationofhighriskwasunawareoftheinformationandthereforeunabletotakeitintoaccount.Thisreview(asdoothers)pointstotheneedformultidisciplinaryinvolvementincapacityassessmentincomplexcircumstances.

SuchmultidisciplinaryinvolvementwasnotedasapositivefeatureinonecaseinwhichalocalauthoritysafeguardingleadofficerhadworkedcloselywithaleadnursetopromoteMental

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CapacityActunderstandingacrossarangeofclinicalgroupsinvolvedwithsomeoneadmittedtohospital,ensuringthatallwereawareofthebestinterestsdecisionsrequirement.

Fourreportscommentonthedifficultiesexperiencedbypractitionersinreachingaconfidentoragreeddecisioninmentalcapacityassessment.Inonecasecapacitywasdescribedas‘deteriorating’butitwasfeltsafenonethelessforthepersontoreturnhome.Anotherreviewcommentsonstaffbeingunsureinthefaceofdifficultquestionsaboutconsenttosexualrelationsbetweenolderpeople.Onoccasion,disputedassessmentswerenoted.Inonecase,whereamultidisciplinarycapacityassessmenthadfoundthattheindividuallackedcapacityforsafeindependentliving,leadingtoanagreedplanforspecialistresidentialcare,anotherclinicianundertookafurthercapacityassessmentanddischargedtheindividualhome,adecisionthatprovedasignificantandinfluentialturningpointinacasethatresultedintheperson’ssubsequentdeath.Anotherreport,praisingtheregularreviewsofcapacitythatwereundertaken,commentsonthechallengesthatfacepractitionerswhenrisksarehigh,andpointstothevalueofanapproachinwhichpractitionersattemptedtostrikeabalancethatpreserveddignityatthesametimeaspromotingsafetybyseekinganindividual’sagreementtomeasuresthatwouldcontainifnoteradicaterisk.

Actionsfollowingcapacityassessmentwerealsoquestioned.Insomecases,afindingthatanindividualhadcapacityledtotheassumptionthatnothingcouldbedonetoaddresstheriskstheyfaced.Conversely,inoneSAR,anassessmentthatresultedinafindingthattheindividuallackedcapacitywasnotfollowedbyanybestinterestsplan;thereporthighlightsthelackofunderstandingregardingcapacityassessmentandalsoaboutDoLS.

TwoSARsmentiontheuseofadvocacyservicesassignificantlearning:inbothcasesanIMCAreferralwasmadetoolatetobeeffectiveinsupportingtheindividualwhohadnootherclearsourceofsupporttounderstandandparticipateindecisions.Despitetheoccasionalpositivecommentsaboveabouthowmentalcapacitywasaddressed,themajorityoftheevidenceandthewidespreadnatureoflessonslearntaboutmentalcapacitypointtofundamentalflawsinhowtheMentalCapacityAct2005isunderstoodandappliedinpractice.

4.1.2. RiskassessmentEighteenofthe27SARsdrawoutlearningaboutriskassessmentandmanagement.Theabsenceortheinadequacyofriskassessmentisnotedin13reviews.Twoofthesecommentmorespecificallyontheabsenceofmentalhealthassessment,inonecasealongsideotherphysicalhealthinvestigations,insituationswhereassessmentwouldhavebeenwarrantedinacaseinvolvingrefusaloftreatment.Another,alsoinamentalhealthcontext,notesthatneithersignificantincidentssuchasthefabricationofillnessnorfailuretoattendappointmentspromptedareappraisalofrisk.Afurthertworeviewsrefertotheabsenceofrobustfireriskassessment,onecommentingthatsuchassessmentshadbecomeroutineandineffective.Inanothercasethereviewfindsthatamoreinvestigativeapproachtoriskwasrequired,andyetanotheridentifiesthattheabsenceofriskassessmentfollowinganindividual’sbereavementignoredwhatcouldhavebeenanticipatedabouttheimpactontheindividual’svulnerability.Theabsenceofjoinedupriskassessmentisnotedinafurthercase,

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particularlyatkeypointssuchashospitaldischarge,orwhentheindividualdeclinedmedicationandwaslosingweight.Hereriskswerepersistentandescalating,butnoactivereviewtookplace.Equally,therewasnocontingencyplanthatcouldprovideapathwayifcarewasobstructedandaggressionwasshowntoserviceproviders.Amultiagencyriskmanagementmeetingwouldhavebeenappropriatebutdidnottakeplace.Inanothercase,eventhoughriskswereacknowledgedandrisk-reductionstrategiesattempted,theiron-goingfailuredidnottriggeranyreviewofthecumulativepicture.Inthesamecase,firesafetyconcernswerenotacteduponbythelandlord,andsomefireservicerecommendationswerenotpursuedastheywereassumedtobethehouseholder’sresponsibility.Inanothercase,theindividual’sneedswerenotconsideredwithinariskframeworkthatwouldhaveresultedincleareridentificationoftherisksposedthroughcertainaspectsofdailyliving,andclearguidancetostaffonrequiredactiontominimisethem.Nomechanismswereavailablethroughwhichtomakevisibletheneedforurgentactioninhighrisk,life-threateningevents,onesucheventeventuallycausingtheindividual’sdeath.

Inonecaserelatingtotheabuseofoneresidentbyanother,earlierriskassessmenthadidentifiedknownrisksofassaultfromtheresidentinquestion,butthiswasnotfollowedbyapreventionstrategy;norwereassaultsthattookplacerespondedtoappropriately–staffsaweachasa‘one-off’occurrence,ratherthanaspartofanestablishedpattern.Inanothercaseinwhichapatternwasnotsufficientlyrecognisedorinterrogated,repeathospitaladmissionsforablockedcatheterweretreatedinisolation,withoutconsiderationofthepossiblereasonsbehindsuchapattern.Inafurthercase,staffwereacutelyattunedtotherisksattachedtohospitaldischarge,andappropriatelytriedtofollowuptheindividualtoascertainhiswellbeing;however,havingfailedtomakecontactwithhim,thelogicoftheconcernwasnotfollowedthrough–furtherfollowupdidnotoccur,andhewasfounddeceasedsometimeafterwards.Thereportcomments“againstthebackdropofallthatwasknownaboutX,staffappeartohavepreferredtobelieveallwaswellpost-discharge”,hintingperhapsatamisplacedoptimism,orabsenceofattunementtorisk,thatwasobservableinothercasesalso.Conversely,thereviewsfoundsomeevidenceofgoodpracticein3cases:inone,severalfiresafetycheckswereundertaken,andappropriatefireretardantmeasurestaken.Inanother,ambulancestaffnotedthepresenceofriskfromthestateofanindividual’shomeenvironment,andraisedanappropriatereferral.Inathird,hospitalclinicianscomprehensivelyaddressedrisksrelatingtohospitaldischarge.

4.1.3. MakingsafeguardingpersonalSeventeenofthe27SARsfindlearningabouthowprinciplesofpersonalisationweretranslatedintopractice.Muchofthislearningarosefromanabsenceofpersonalfocusinthecasesinquestion,inbothinstitutionalanddomiciliarysituations.Fivereviewscommentonpersonalisationinresidentialcareorgroupliving.Inonecasethereviewfoundlittleevidenceofpersonalisedcarewithintheinstitutioninquestion,withpracticefocusingonsystemsofcareratherthanontheindividual.Theirneeds,wishesandpreferenceswerenotalwayslistenedto,andrecordsthatcouldhavereflectedtheirindividualidentitywerenotupdated.Therewasanabsenceofattentiontosensoryimpairmentand

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physicalhealthneeds,alackofstimulation,andfailuretorecogniseemotionalneeds.Agencies’systemsandprioritiesdominatedinanothercasealso,allowingtheindividualtodropfromsight.Anotherindividualwasplacedinacarehomethatwasphysicallyunsuitableforhim,resultinginotherresidentsbeingexposedtointeractiontheyfoundchallengingandwhichtriggeredanincidentthatresultedinthedeathofanother.Inafurthercase,whereitwasknownthattheindividualwouldhavewishedtobeinvolvedindecisionsaboutherplacement,suchinvolvementwasnotroutinelyattemptedorachievedwhenplacementwasbeingsought.Inanotherinstitutionally-basedsituation,achangeinthebehaviourofoneindividualwasnotrecognisedasaresponsetoherfearofanotherresident,ortakenintoaccountinaplantoensureherprotectionfromabuse.Areviewinvolvingacarehomeclosurefoundthatthecareplansthataccompaniedresidentsintotheirnewcarehomesgaveonlybasicinformationsuchasnextofkin,GPandmedication,withnomentionoftheirpreferencesandhabits,orinformationtoassistthoselookingafterthemtoprovidepersonalisedcare.Areviewthatconsideredhospital-basedcarenotedalackofconcernshownbyhospitalstaffforanindividual’spainanddiscomfort,includingfailuretoprovideapressurerelievingmattress,whilewaitingfortreatment.

Afurthereightreviewscommentonhowcareathomehadbeendelivered.Intwocases,theservicefromCommunityNursinghadbeenunreliableandirregularandinonecaseinsufficientattentionhadalsobeengiventotheindividual’sneedforsupportinmanagingacolostomybag.Afurtherreportcommentsonanabsenceofcompassiontowardsanindividual’sexperienceofpressureulcerdamageandpain.OneSARnotesthattheindividualhadremainedrelativelyinvisibletoagenciesformanyyears,despitehavingneeds(legulcersandsensoryimpairment)thatwouldhaverequiredattention.InonecaseaGPwasnotedtohavespokendisrespectfullyinfrontoftheindividual,perhapsasaresultoflackofawarenessofhercondition.Inanothercase,theindividualhadcomplainedthatcarestaffhadchattedtoeachotherinalanguagehedidnotspeak.TworeviewscommentoninsufficientcontactwiththeindividualbyAdultSocialCare;inonecaseanabsenceofhomevisitmeantthattheindividual’ssituationhadnotbeenfullyassessed,andinanotherapractitionerhadfailedtograsptheseriousnessofthesituation,leavingindividualcareandhousingworkersunsupportedwhentheytriedtorespondtotheindividual’sneeds.Inanotherexample,theprofessionalnetworkfailedtoensuretimelyendoflifecare,resultingintheindividualbeingunabletoachievehiswishtodieathome.Inanothercase,decisionsaboutpainmanagementweretakenabouttheindividualratherthanwithhim.Andinyetanother,allcontactwithanindividualgivennoticetoleavehishomewasundertakenbyphoneorletter,withnoface-to-facecontact;theimplicationsforhishomelessnessandtheimpactonhismentalhealthdidnotformpartofprofessionals’discussions,andnoperson-centredneedsassessmentwasundertaken.Inseveralcases,communicationwiththeindividualwasreplacedbycontactwithfamilymembers.Inonesuchcase,familyresistancetooutsideinvolvementinfamilymattersdeterminedtheagencies’responses,leavingneedsunmet;inanother,withoutahomevisittoomuchwastakenatfacevaluefromtelephonecontactwiththeindividualandhisrelativecarer.

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Converselythereweresituationsinwhichpersonalisationwasprioritisedtotheexclusionofoptionsforintervention:inonecasethismeantthattherisksposedtootherswerenotmanaged,becausetheindividual’srejectionofinterventiondeterminedtheagencies’actions.Inanothercase,prioritisationofanindividual’swishesandfeelingsaboveotherconsiderationsresultedintheindividualbeingdischargedfromhospital,andsubsequentlydying,despiteabroadlysharedinterprofessionalviewthathedidnothavecapacitytoliveindependently.Incontrast,anumberofSARscommentpositivelyonhowpracticeplacedtheserviceuseratthecentreofwhatwasdone.Inonecase,practitionersascertainedtheperson’sviewsandwishesand,whilerespectinghisviews,sharedtheirperceptionsofriskanddangerswithhim.Amultidisciplinarymeetingwasheldathishomeinordertopromotehisparticipation.Anotherreportcommentsonhowstaffworkedtoachievethewishesofanindividualwhohadnotexperiencedpersonalisedcareinhospitalandwhowishedtodieinsteadinthecarehome.Inanothercase,theprimaryandalliedhealthpractitionersandcareagencystaffwerenotedtohaveengagedinperson-centredpractice.Staffinafurthercaseshowedcompassion,concernandresilienceinplacingthepersonastheirfocusofconcern,despitethisfallingoutsidetheremitoftheirrole.Inothercases,thepersonalfocuswasmoremixed.Oneyoungperson’sphysicalhealthneedsandperson-centredcareplanwereroutinelyandregularlyreviewed,butafailuretoresolvehisfinancialposition,andaresultantlackoffunds,compromisedhispursuitofeducationandothervaluedactivities.Theuseofadvocacyasameansofpromotingpersonalisationinsafeguardingdidnotfigurelargeinthelearningfromthereviews.OnlythreeSARsmentionadvocacy:onenotingthatanindividual’sdaughterwasofferedbutdeclinedanadvocate,andanothercommentingthatreferraltoanIMCAhadcometoolatetobeofanyvalue.Thereportcomments“professionalsdonotfullyunderstandtheroleofstatutoryadvocacyservicesinsupportingadultsatriskinkeydecisionsaffectingtheirwellbeing,withtheresultthatadultsatriskareleftwithouttheirwishesandfeelingsknownorarticulated”.Athirdreviewnotesthattheneedforadvocacywascompletelyoverlookedwhiletheindividualwasinacarehome,andthatthereforenoindependentperspectivewasgivenonhisbestinterests.Converselywhenanadvocatewasfinallyappointedwhiletheindividualwasinhospital,thevalueoftheroleinpromotingtheindividual’spersonalperspectivewasamplydemonstrated.

4.1.4. WorkwithfamilymembersSixteenofthe27SARsextractlearningfromthewaysinwhichworkwithfamilymembersandcarerstookplace.Lackofinvolvementofthecarerwasacommontheme,figuringin8ofthecases.In2cases,thismeantthatimportantinformationabouttheindividual’scareneeds,andtheimpactoffamilyhistory,wasnotbroughtintoconsideration.Inanothercase,importantinformationaboutprofessionals’rolesandcontactdetailswasnotprovidedtoacarer.Inafurthercase,thecarerprovidedadifferentrecordofcontactswithprofessionalsfromthosenotedintheprofessionalrecords,indicatingadifferenceofperceptionaboutthediscussionsthathadtakenplace.Familymembersinadifferentcasehadnotbeenadvisedofproblemsrelatingtothecareoftheirrelativeandwerenotconsultedonmedicalaspectsofhiscare.

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Andanotherreviewcommentsthatthefailuretoliaisewithavailablefamilymembersrepresentsamissedopportunitytoengagetheminsupportiveactions.Timelycarer’sassessmentwasmissingin4cases,withafurtherreviewnotingthatacarer’sassessmentwasofferedanddeclined.Theexperienceoffamilymembersandcarersinothercaseswasmoremixed.Inoneexample,goodinvolvementandcontactearlyoninthecasetailedoffandthecarer’sconcernswerenotrespondedto.Inanother,wheretheparentsofayoungpersonwerecloselyinvolvedandheldauthoritytomanagetheirson’sfinances,theywerenotlistenedto,andtheDWPtransferredtheappointeeshipovertheirson’sfinancestothelocalauthoritywithoutanyconsultation.InanothercaseHousingstaffrequestedandreceivedinformationfromarelativebutdidnotsharesufficientdetailonwhyparticulardetailswerebeingsought,withtheresultthatthefamilymembermaywellnothaveappreciatedthesignificanceofthequestionsbeingaskedorofthewaytheresponsesbeinggivenwouldbeinterpreted.Equally,inthiscasetheserviceuserhadnotbeenaskedtoconsenttotheinvolvementofhisrelative,norhadhebeenformallyassessedaslackingcapacitytodeterminewherehemightlive.

Onereviewnotesthedifficultiesthatstafffacedinattemptingtoinvolvefamilymembers,recognisingthatfamiliesmaynotalwaysbewellplacedtonoteandraiseconcernsaboutcare.Alackofclarityisalsonotedaboutwhatcouldbecommunicatedtorelativesaboutproviderfailure,compromisingtheopennesswithwhichsuchdiscussionscouldbeapproached.Anothernotesthefailuretoenquireintofamilyhistoryandthedynamicsbetweenacouple,andtochallengeorexpressscepticismabouttheinformationtheywereprovidinginthelightofotherevidenceavailable.4.1.5. Theimportanceofunderstandingtheindividual’shistoryandrelationshipsTheimportanceofprofessionalsunderstandingtheindividual’shistoryandelementsoftheirpriorexperience,includingsignificantrelationships,emergesin11ofthe27SARs,oftenfromcircumstancesinwhichpractitionershadfailedtorecognisedkeyfeaturesinanindividual’slifehistory.Inseveralcases,stafftendednottoseekanunderstandingofthemeaningbehindaperson’sbehaviour.Forexample,inaself-neglectcase,practitionersgaveinsufficientattentiontothepossibleanxietiesthatmightunderpinreluctancetoacceptcare,whichincludedfearsaboutlossofindependenceandpossibleseparationfromestablishedrelationships.Inanother,riskassessmentandriskmanagementwerecompromisedbylackofunderstandingoftheindividual’shistory.Inanother,staffunderestimatedthecomplexityoffamilydynamicsbetweenanolderadultandherdaughters,anddidnotrecognisewarningsignsaboutpossiblecoercionandcontrolbyadaughter.Inafurthercase,staffgaveinsufficientconsiderationtotheimpactofaparent’sself-neglectontheirabilitytoparent,andtotheimpactofpastandpresenteventsontheirsignificantlackofself-care.Practitionerssometimesdidnothaveimportantfactualknowledgeaboutanindividual:onesocialcarepractitionerdidnotchecktheirownagencyrecordsandwasthereforeunawareofimportantelementsofthecasehistory;hospitalstaffhadinsufficientknowledgeofan

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individual’smovingandhandlingrequirements,andoftheirfearofhospitalsasaresultofpreviousexperiences;asocialworkerwasunawareofthestatusofarelativewhowasafinancialappointee.Inothercases,historicalinformationwasknownbutnottakenaccountof.Inonecase,staffhistoricallyprovidinglong-stayinstitutionalcarehadtransferredwiththeindividualtoacarehomeenvironment,andentrenchedpatternsofinstitutionalisedcarehadcontinued,withinsufficientrecognitionbycommissionersoftheirimpactontheindividual.Inanother,whereoneresidentcarriedoutanumberofassaultsonanother,staffdidnottakeintoaccountaperpetrator’shistoryofassaultinothersettings,andthereforedidnotviewtheassaultsasarecurringpattern.Reviewsinanothercasedidnottakeaccountoftheperson’sknownhistory,orofpreviousencounterswithaparticularagency,bothofwhichwouldhaveaffectedpresentengagement.4.1.6. ChallengesofengagementSARreportscommonlymentionchallengesrelatingtohowpractitionersengagedwiththeindividual.In9ofthe27cases,significantlearningisdrawnoutaboutthisaspectofpractice.Arecurrentthemewasthatstaffgaveuptoosoonandinsomecasesavoidedengagingwithcertainaspectsofanindividual’ssituation.Inonecase,statutoryserviceshadnotsoughtengagementwithanindividualoverhisuseofalcohol,leavingdirectcareworkers,whohadsucceededinbuildingarelationshipwithhim,exposedwithoutguidanceonworkingwithhisalcoholuse.Inanother,arelativefeltthatcarehomestaffhadgivenuptooeasilyonencouragingtheolderpersontoparticipateinactivities.WhenaHousingDepartmentsharedwithAdultSocialCaretheirconcernsaboutanindividual,thereferralresultedonlyinaphonecall,duringwhichtheindividualdeclinedassessmentandnofollow-uptookplace.Inafurthercase,someagenciesonlyofferedappointmentsontheirownterritory,nottakingaccountofbarrierstoattendance,anddidnotfollowupmissedappointments.Inanother,theprofessionalnetworkcommunicatedwithanadultdaughterratherthanwiththeindividualherself,acceptingthedaughter’sreassurancethatnothingwasneeded,andmissingopportunitiestogaintheindividual’sownperspectiveonwhatinfactwerecomplexfamilydynamics.Infourcases,theSARcommentsontheabsenceofanystrategytosecureengagement.Inonethiswasdrivenperhapsbytheprofessionalnetwork’suncertaintyaboutthenatureoftherelationshipbetweentwowomenwholivedinthesamehousehold,leavingitunexploredforfearofgettingitwrong.Theabsenceofstrategy,andofopendiscussionabouttherelationship,wascompoundedbycareprovidersspendingtoolittletimewiththeindividuals,raisingquestionsaboutlevelsofskillandtraining.Inanother,evensustainedlackofengagementwitharangeofagenciesdidnottriggeranydiscussionbetweenthemofalternativewaysforward.Inthethird,theleadprofessionalwasstronglycriticisedforalackofengagementwith,andcommitmentto,theindividual.Inthefourth,warningsignsaboutdepressionandself-neglectwerenotaddressed;neithertheindividualnorhispartnerwerechallengedappropriatelyaboutevidenceoftheconsequencesofasignificantlackofself-care,asaresultofwhichtherewasnotreatmentplan.

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OnamorepositivenoteoneSARnotesfeedbackfromfamilymembersabouthowattentiveandkindcarehomestaffhadbeenwiththeirrelative.Andanothercommentspositivelyontheconsistencyofsupportofferedfromayoungperson’sadviserandfromdrugandalcoholservicestaff.ContinuityofpersonnelemergedinseveralSARsasanimportantfactorthatsupportedorinhibitedengagement.AcaremanagementmodelofworkflowinAdultSocialCare-inwhichshort-termassessmentandcareplanningwasfollowedbyacasebeingclosedormadedormantpendingreview-drewcomment.Onereviewofaself-neglectcasenotesthatcaremanagementimpactednegativelyonthedevelopmentoftrustthroughwhichmoreassertiveandpersuasiveinterventionscouldhavebeendelivered;anothercommentsthattheabsenceofcontinuitymeantthatAdultSocialCarewereunawareofchangingneedstriggeredthrougharapiddeclineintheindividual’shealth.Thereweremorepositiveexamplesofhowteampracticehadbeenadjustedtoallowcontinuity,onereviewnotinghowthisflexibilityhadpromotedgoodengagementwiththeindividual,andanotherhowthenatureofriskinthecasehadpersuadedmanagementtoallowittoremainopeninordertofacilitatecontinuityofworker.AGPpracticehadchangeditsrotasystemforcarehomevisitstoimprovecontinuityofdoctorfortheresidents.Anindividualinonecasehadrespondedverywelltofamiliarcarestaff,allowingthemtoattendtoanintimatecareneedthathehadrefusedtoallowhealthcarestafftoview.Butthelossofhisregularworkercausedhimconsiderabledistress.

4.1.7. FocusonrelationshipWhilerelativelyfewSARsspecificallyrefertorelationship-basedpractice,thequalityoftherelationshipwiththeindividualisimplicitinthelearningthatemergesabove,particularlyinthefocusonmakingsafeguardingpersonal,understandinganindividual’shistory,andseekingpositiveengagementovertime.OneSARcommentsonhowaninitiallygoodrelationshipbetweentheindividualandcareworkersinthecarehomedeterioratedasherdementiaprogressed,withnoreassessmentofriskandneeds.Twoothersrefertotheabsenceoffocusonbuildingarelationshipwiththeindividual,inpartbecauseofthewayinwhichworkflowwasorganised(exploredfurtherinthefollowingsection).Inanothercase,conversely,workersshowedahighleveltocommitmenttoretainingengagementascircumstanceschanged.Andagaininanothercaseinwhichadistressedindividualhadtoattendhospital,acareworkerwhoknewhimaccompaniedhim,theSARnotingthisasgoodpractice.Oneaspectofrelationship-basedworkisthequestionofhowtherelationshipdynamicsbetweenfamilymembersareaddressedbypractitionersworkinginthecase.Inoneexampleinvolvingamotherandson,thepowerimbalancebetweenthemwasrecognised,butnoworkwasundertakentoaddressit.Inanother,thoseprovidingcaredidnotunderstandtherelationshipbetweentwopeoplelivinginthesamehousehold,andtheimpactofthatrelationshiponhowthetwoindividualsrelatedtoprofessionalswasnottakenaccountof.Inathird,therelationshipbetweenahusbandandwifewasnotopenlyexplored,andhowthismightbeimpactingontheirparentingandonthehusband’ssignificantself-neglect.

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4.1.8. SinglebutimportantelementsofdirectpracticeInadditiontothenotablethemesabove,individualSARsnotedarangeofindividualcircumstances.WhiletheydonotconstituterepeatpatternsacrossanumberofSARs,theyarenonethelessimportantpracticeconsiderationsonwhichtoreport.Transitionfromchildrentoadults’services:OneSARinthesamplediscussesthetransitionofacareleavertoadultservices.Itnotesthattheyoungperson’scasewasroutinelyreviewedbychildren’sservices,buttherewasnojointactionplan,hermentalhealthneedswerenotunderstoodorappropriatelyrespondedto,andpatternsinherbehaviourwerenotaddressed.Practitioners’fearsofviolence:OneSARnotesthatpractitionersfeltatriskofverbalandphysicalviolence,andcommentsthattheirfearswerenotexploredatthetime.Lackofspecialistunderstanding:Inonecase,theSARnotesthatpractitionerslackedspecialistunderstandingoftheimpactofsevereconstipationandbowelobstruction.

Failuretofollowcareplan:Inanothercase,stafffailedtofollowacareplanrequirementfortheindividualtosleepinaparticularposition,resultingindeaththroughsuffocation.Poorqualityofannualreview:OneSARnoteshowanannualreviewwaspoorlyconducted;onlythecareproviderwasinvited,nodocumentationwasrequestedfromotheragencies,nopreparationwasundertakenwiththeindividual,andthereviewrecordederroneousinformationaboutacriticalelementoftheindividual’sdailyneeds,directlyrelatedtothecircumstancesinwhichhedied.

4.1.9. ConcludingcommentonlearningaboutdirectpracticeOnefeatureofdirectpracticewasconspicuousbyitsabsenceinthelearningnotedinthereviews.Onlyonereviewmakesanycommentabouthowethnicitywasaddressedinpractice,notingthattheagenciesinvolveddidnotidentifytheracial,cultural,linguisticandreligiousidentityoftheindividualduetotheirlimitedcontactwithhim.Thismirrorstheabsenceofethnicityasafeatureofthenotedcharacteristicsofthecasesinquestion,andisworthyoffurtherexplorationintermsofSARquality:isitthecasethatthereisnothingtobelearntabouthowethnicityisaddressedinadultsafeguardingintheremaining26cases,ordoesthisrepresentamissedopportunityforlearning?

4.2. Domain2:Organisationalfeaturesthatinfluencedhowthepractitionersworked

TheseconddomainoflearningthatemergedfromtheSARsrelatestoarangeoffactorswithintheinternalworkingsofagencies,whichaffectedhowpractitionersinthoseagencieswereabletowork.Thethemesinthisdomainarerecordsandrecording,safeguardingliteracy,managementoversight,resources,supervisionandsupport,organisationalpolicies,legalliteracy,agencyculture,staffinglevelsandmarketfeatures.

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4.2.1. RecordsandrecordingNineteenofthe27SARsidentifylearningabouthowpractitionersrecordtheirwork,orhowtheorganisationprovidesthemwithrecordingsystemsandprocesses.Theissueswerediverse,butacommonthemewasanabsenceofkeyinformationinthecaserecord.Oneagency’srecordscontainedtoolittleinformationaboutasignificantbestinterestdecision.Theindividual’slearningdisabilitypassportinthesamecaselackedimportantinformation,andwasnotroutinelyavailablewhenhehadmedicalandhealthappointments.Inanothercase,anuncleardischargesummarymeantthatCommunityNursingservicewereconfusedaboutwhetherservicesshouldberesumed,asituationcompoundedbywhattheSARdescribesasaconvolutedandcumbersomeadministrationprocessthatreliedonpaperandemailcommunications.Inanother,standardassessmenttoolshadnotbeenused,andtherecordofassessmentwasthereforeoutoflinewithexpectedprotocols.Inthesamecase,heathrecordscontaineddivergentinformation,careandtreatmentplanswerenotupdated,andthedischargesummaryheldlimitedinformation,withnodetailoftreatmentforulcers.Thecarehomehadnotkeptadailynutritionallog,soweightlosswasnotevidencedandthereforetheopportunityfortimelyreferralstospecialistswasmissed.Inanothercase,involvingmultiplehospitaladmissions,transfersummarieswerenotavailableinallcases.Inanothercase,thereportfromahospitaltoaGPcontainedonlysomeoftheavailableinformationaboutaperson’slackofself-care.AndafurtherSARnotesthatreferralformsbyaGPwerenotcompletedthoroughly,andthatreportstotheallocationdecisionpaneldidnotcontainacomprehensiveneedsassessment.

Insomecases,recordsweresimplymissing.OneSARnotesanabsenceofclinicalnotesin20%ofallCommunityNursingvisits.Appointmentswerenotalwaysrecordedinthehomenotes,resultinginthepatientbeinguncertainwhenavisitwasdue.Andthewayinwhichsomevisitswererecordedontheelectronicdatabaseimpliedthatthepatienthadbeenseenwheninfacttheyhadnot.Theshortcomingshadnotbeenpickedupbytheorganisation’squalityassurancemechanisms.AnotherSARnotesthatatissueviabilitynursevisitcouldnotbeconfirmedfromtherecords.Inaccuracieswereobservedtoo.OneSARprovidesexamplesofinaccuraterecordingandofdelaysinuploadinginformation,resultinginrecordsthatwereatkeypointsoutofdate.DelayintransferringinformationbetweenGPsinanothercasemeantthatthoseinvolvedlackedinformationaboutthecasehistoryandcurrentconcerns.Inafurthercase,ahospitalhad5differentaddressesforapatient;incorrectentrieswerenotcorrected(andweresuppliedtootheragencies)evenwhenitwasknowntheywerewrong,andthepatientwasfinallydischargedtothewrongaddress.Recordsdidnotalwaysprovideaclearaudittrailondecisionsmade.Therecordsinonecasedidnotindicatewhyanindividualhadbeenplacedinasleepingpositionthatcontravenedtheestablishedcareplan.Inanother,therewerenorecordedminutesofahospitalmeetingheldaftertheindividual’sdeath,atwhichadecisionwastakennottoconductaseriousincidentinvestigation.Inafurthercase,itisunclearhowanallocationdecisionpanelreacheditsdecisionagainstthecriteriasetoutfortheoperationofitsdecision-making.Sometimesrecordsdidnotplayaroleinon-goingdecision-making.Inonecase,aseniorpractitionertookadecisiontocloseareferralthatasocialcareassistanthadescalated,when

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agencyrecordsifconsultedwouldhaveshownaclearlyemergingpatternofconcern.Poorrecordingofdetailinanothercasemeantthatissuesofconcernwerenotpickeduporfollowedthrough,andinafurthercasetooinadequaterecordingmilitatedagainsttheemergenceofacumulativepictureofrisk.Inafurthercase,basicinformationwasmissingincareplansandwasthereforenotavailabletodomiciliarycarers.Technologyalsofeaturedinthelearningaboutrecords.OneSARnotesthatAdultSocialCaresystemsdidnotmakeitpossibletomatchupcasesinwhichacommonfriend/carerwasimplicated,wheresimilarissuesofneglect/self-neglectwerepartofthepictureinbothcases.Anotherobservesthatadatabasehadnotmatcheduprecordsoftwoclientswhowereinfactthesameclientusingdifferentnames.Inanothercase,theSARnotesthattheAdultSocialCarecaserecordsystemwasdifficulttofollow,tocross-referenceandtorefresh.Andinafurthercase,thelocalauthoritydidnothaveasystemthatcouldalertstafftothefactthattherestartofameals-on-wheelspackagehadnotbeenactivated.HospitalITsystemsfeaturedintwocases:inone,thesystemdidnotenableasafeguardingflagtobeattachedtoapatient’srecord;intheother,asafeguardingreferralmadebythehospitalontheperson’sadmissionfromacarehomewasnotlinkedtothepatient’srecord,sotherewasnotriggerforreflectionaboutthewisdomofdischarginghimbacktothesamehome.Inafurthercase,theabsenceofphotographicevidenceinrecordsmadetissueviabilitytrackingandtreatmentdifficult.

4.2.2. SafeguardingliteracySixteenofthe27SARsraiseconcernsabouttheextenttowhichagenciesandtheirstaffhadknowledgeandconfidenceinsafeguardingmatters.Failuretorecogniseapresentingpictureascauseforsafeguardingconcernwasacommonfeatureinanumberofcasesandacrossanumberofagencies,includingAdultSocialCare,CommunityNursing,carehomes,healthcareagencies,shelteredhousingprovidersandhomecareproviders.Oftenformalsafeguardingprocesseshadthereforenotbeenused.Inonecase,theabsenceofsafeguardingalertswasattributedtostaffnothavingbeengivenguidanceortrainingsubsequenttoself-neglectbeingincludedinadultsafeguardingonimplementationoftheCareAct2014,andtotheindividualnotfittingwiththedominantprofileofpeoplewhoself-neglect.Inanothercase,independentprovidersdeferredtotheviewsofthestatutoryagenciesratherthanpursuingtheirconcerns.Inanother,areviewingofficerwhobecameawareofparents’concernsaboutmismanagementoftheirson’saffairsattempted(unsuccessfully)toresolvetheissuesindividuallyratherthanensuringthatasafeguardingresponsewasprovided.Inanother,thelocalauthority’sriskassessmentprocesshadnotidentifiedself-neglectasasafeguardingissue.Inafurthercase,neitherthetenancymanagementofficernormanagers,whennotifiedaboutanindividual’ssuicidalthinkingfollowingtheirrefusalofhistenancyapplication,consideredpassingconcernsontootheragencies.AnotherSARobservesthatnocumulativeoverviewofriskwastaken;missedappointmentsatahealthcentredidnotresultinanyproactivefollowup,andAdultSocialCaredidnotfollowupconcernsthattheindividualwasnotcopingathome,resultinginmissedopportunitiestotriggerasafeguardingresponse.OneSARobservesthataserviceuser’scomplainttothecareagencythatcareworkersstolehismoneywasnotraisedbytheagencyasasafeguardingreferral,nordidthehousingproviderinvokesafeguardingprocesseswhensuspectingthataformercareworkerwasvisitingtheindividualandengagingin

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financialabuse.Inthiscase,only4of7safeguardingconcernswereraisedassafeguardingreferrals.AnotherSAR,reviewingassaultsbyoneresidentialhomeresidentonanother,foundthattheincidentsweredealtwithunderacaremanagementframeworkratherthanasafeguardingframework.Inthiscasethereweredelaystoooncetheneedforsafeguardingwasrecognised,asonlycertainstaffhadtheauthoritytomakereferrals.Seriousomissionisnotedinacaseinvolvingamanadmittedfromacarehometohospitalwithtissuenecrosis,followingaperiodinwhichnocareworkers,visitingprofessionalsorfamilymembershadraisedquestionsabouthislackofimprovement,or(latterly)aboutthesmell(whichwasimmediatelynotedbyambulancecrew)andwhereeithertheGPorCommunityNursescouldhaveescalatedconcernstoamultiagencymeeting.

Inothercases,safeguardingreferralsweremadebutnotrespondedto.Inonecase,section42referralsweremerelypassedtoAdultSocialCareteamstaffwhowerealreadytryingtoengagewiththeindividual;theywerenotusedtopromptanenquiry,oranymultiagencyconsiderationofrisk.ButbothAdultSocialCareandMentalHealthserviceswithdrewwhentheywereunabletoengageand,despitenumerousalerts,safeguardingriskswerethereforenotexplicitlyconsidered.Inanothercase,thelogicofahospitalhavingraisedasafeguardingconcernabouttheconditioninwhichanindividualwasadmittedfromacarehomewasnotpursued,ashewasdischargedtothesamehomewithoutanyprotectionplaninplace.Inafurthercase,asafeguardingreferralaboutanindividualinhospitalwasclosedafteraninitialconversationwiththewardwhoseactionswerethesubjectofthealert,withoutanyattempttotriangulateinformationfromotherswhowouldhaveprovidedalessreassuringperspectiveonthesituation.Andinacaseinvolvingasafeguardingreferralaboutassaultsinaresidentialhome,contractsandcommissioningwithinthelocalauthoritywerenotadvisedoftheconcerns.Morepositively,oneSARnotesthatboththeAmbulanceServiceandthehospitalraisedappropriatesafeguardingconcernswhenanindividualwasadmittedinastateofsignificantself-neglect,resultingintheimplementationofaprotectionplan.AndanothercommentspositivelyonAmbulanceandCommunityNursingstaffraisingreferralsaboutanindividual’sdeteriorationintoself-neglect,includingpossibleneglectofhispressureareasbycareworkers.Theprovisionoffeedbacktoreferrersontheoutcomeofenquirieswasnotedasgoodpractice.Finally,illustratingagainthemixedpicture,PoliceandAmbulancepersonnelwerediligentinraisingmultiplesafeguardingalertsregardingayoungpersonatriskbutnoneofthesewereinvestigatedbythesafeguardingadultsteam;allalertswerepassedontothoseattemptingtosupporttheindividualthroughtransitionfromleavingcareandnomulti-agencyreviewwastriggeredofincidentsthatformedarepeatingpattern.

4.2.3. ManagementoversightThirteenofthe27SARsdrawattentiontotheimportanceofmanagementoversightofpracticeinhigh-risksituations.Intheoneexampleofgoodpractice,managerswereinvolvedincasediscussionswithasocialworker,anddemonstratedflexibilitytoenablethecasetostayopentoensurecontinuityofpractitioner.Wheremanagementoversightwasproblematic,thiswaslinkedtoanumberofissues:theabsenceofsystemsthatcouldalertmanagerstoerrororomission;thedegreetowhich

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managerswereproactiveinscrutinisingpractice;andwhetherpractitionersthemselvesescalatedcasesformanagers’attention.Inoneexample,theorganisationalcontextforpracticewithinthelocalauthorityinquestionwasdescribedasbeingmarkedbyfailuresinservicemanagementandleadership.Thiswascompoundedbyafailureonahousingprovider’sparttoimplementtherecommendationsfromapreviousfireriskassessment,andalackofclarityaboutfireevacuationprocedures.Inanothercase,therewasnomanagementoversightofcareandtreatmentplans,orcoordinationoftheworkofanumberofdifferenthealthcarepractitioners.Therewaslackofoversighttooofprescribedmedication.Inafurthercase,carehomemanagersdidnotensureanappropriatestandardofcleanliness,raisingconcernsaboutinfectioncontrolandothermattersrelatingtoresidents’health.Andintwoothers,managersdidnotreviewpractitioners’decisions,nordidmanagersoffersupporttostaffwithchallengessuchasservicerefusal,ordilemmasofcapacity,consentandchoice.Elsewhere,theabsenceofrobustsystemsforauditingcaserecordsleftuncheckedapatternofservicefailuresonthepartofpractitioners,andthescaleoftheshortcomingsinhowhealthcarewasprovideddidnotemergeuntiltheSARwasundertaken.

Inonecase,wherepractitionersinHousingserviceswerechargedwithimplementinganewallocationoftenancypolicy,managersdidnotprovideadequatescrutinyatatimeofchange,andthereforedidnotidentifytheabsenceofassessmentsofneedandrisk;reportswerenotscrutinised,andtherewasthereforenodiscussionorchallenge.Equallythereareexamplesofpractitioners’failuretoescalateconcernstomanagers.Inoneexample,riskmanagementstrategieswereproducingnochangeandriskthereforeremainedhigh,butmanagerswerenotalerted.Inanothercase,managerswerenotwellinformedaboutthechallengesposedbyacommissioninggapinrelationtocomplexmentalhealthneedsofyoungpeople.Inanother,inwhichaclient’sfinancialaffairshadbeenmismanaged,anyoneofanumberofuntowardeventscouldhavealertedthoseinvolvedtoalevelofconcernthatrequiredescalation,butnonetookplace,raisingquestionsabouthoworganisationsensurethatasequenceofsmallworries,routinelyabsorbedindailypractice,canberecognisedasapatternthatrequiresescalation:howmanyambersdoesittaketomakeared?Conversely,escalationdidnotalwaysproduceasatisfactorymanagementresponse.OneSARfoundthatstaffhadappropriatelyescalatedconcernsaboutanunsafedischarge(althoughthedecisionwasconveyedtothewardtoolatetopreventit).However,thehospital’sresponsewastoallocatetheinvestigationtothemedicalpractitionerwhohadbeendirectlyinvolvedinthedecisiontodischargethepatient,whichtheSARnotesasaconflictofinterestandpoorgovernanceonthepartofthehospital.

4.2.4. ResourcesThirteenofthe27SARsidentifylearningrelatingtohowanabsenceofresourceshadimpacteduponthecasesreviewed.Inonecaseitisnotedthatlackofresourceshinderedhealthcareproviderinput.Inafurtherexample,CommunityNursingworkloadswerestretched,andthecapacityoftheservicewasseverelylimited,withrequestsbeingmadetocommissionersforfurtherfunding.OneSARnotesthattherequiredmovingandhandlingequipmentwasnotavailableinahospitalemergencydepartment.Anothernotestherewere

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inadequatesuppliesofcathetersandpads,andpointstotheneedtorecognisetheconstraintsunderwhichorganisationsareoperating.AfurtherSARobservesthatashortageofadministrativestaffmeantaseriousdelayinnotifyingaGPthatapatientwasbeentransferredbackfromhospitalinvestigations,andreorganisationinAdultSocialCareresultedinabacklogofassessment,wheretherewasnostrategytodealwithpriorityreferrals.

Insomecases,lackofresourceswasattributeddirectlytofinancialconstraint.OneSARcommentsthatAdultSocialCareinonecasewasunwillingtoexceedanotionalmaximumcarepackagespendeventhoughthelevelofcarewasnotmeetingtheindividual’sneeds.Recommendationsthatacarepackageshouldaccommodatetheneedfortheindividualtoberepositionedperiodicallywerenotmet,andreferraltotheClinicalCommissioningGroupforcontinuinghealthcareassessmentdidnotreceiveatimelyresponse.Inafurthercase,theimpactofausteritymeasuresonthecarehomelimitedtheopportunitiesavailabletotheindividual,andthushisqualityoflife.Timeasaresourcewassometimesinshortsupplyasaresultofservicedemands.ThedemandsonAdultSocialCarementionedinonecaseincludedasignificantriseinworkrelatingtotheDeprivationofLibertySafeguards,theappointmentoftemporarymanagers,andthecollapseofarotaforbestinterestsassessments,withnoarrangementsputinplaceforsocialworksupervision.Inanothercase,therewasasignificantgapinOTprovision.InafurthercasetheSARnotesconcernsthatanewlyestablishedriskpanelmaybeunabletorespondquicklyduetoahighlevelofdemand,andidentifiestheneedforadequateresourcingofthisroutefordecision-making.ThebenefitsofasystemforGPstodiscusscaseswithAdultSocialCarewereapparent,butitwasrecognisedthatresourceswerenotavailabletorollthisoutacrosstheborough.Afurtherkindofresourceshortagerelatedtoalackofspecialistplacements.Inonecase,thereportnotedashortageofsuitableprovisionforverytroubledyoungpeople,andparticularlyofservicesthatcouldreachoutandsustaininvolvementinthefaceoferraticengagement.Inonecase,theindividualhadbeenmovedfirstfromanacutepsychiatricwardandthenfromanotherhospitalduetopressureonbedsinbothinstitutions;thelocalauthority,respondingtopressurefromthehospital,wasobligedtomakeaplacementthatwasnotsuitable,becausetheavailabilityofresourcesforpeoplewithdementiadidnotmatchthedifferentneedstheyexhibit–whattheSARtermsalackof‘requisitevariety’.Finally,staffingasaresourcedrawscommentintwoSARs:inthefirst,EmergencyDepartmentstaffhadbeenunfamiliarwiththeneedsofalearningdisabledmanwithcomplexneeds.ThesecondnotesthatnotallHousingstaffhadbeentrainedinanewallocationprocedure,resultinginalackofclarityaboutthecontentandstructureofrequiredreportsforallocationpanel.

4.2.5. SupervisionandsupportTenofthe27SARshighlightlearningthatrelatestosupervisionandsupportofstaff.Inonecase,goodsupervisionpracticewasnoted:whilecarehomesupportworkershadnoformalqualifications,theydidreceivesupervision,andalthoughnottrainedincathetercaretheyweresupervisedwhenattendingtothis.

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Theabsenceorinadequacyofsupervisiondrawscommentinthreecases.Inoneexample,acarehomeagencyfailedtoseethatthecareworkerrequiredsupervisionandthesocialworkerinthesamecasereceivedlittlesupervisionalso.Inanothercase,supervisionofHousingstaffisdescribedas‘lighttouch’.Elsewhere,thesupervisionprovidedfocusedmoreontheroleofservicesthanuponthepossiblereasonsforanindividual’sbehaviour;theSARnotedthatitseemednottobeusedtoreachforanyunderstandingofthesituation,ortodevelopaplanforaddressingthechallenges.Thereisconcernaboutthedisappearanceofsupervisionrecordswhenstaffleavetheemploymentofanagency.Inonecase,suchrecordswerenotavailableaftertheworker’sdeparture,andthuscouldnotformpartofthecontinuityofdecision-makinginthecase,orcontributetoaclearaudittrail.ThesupervisoralsohadbeenalocumemployeeandhadleftbythetimetheSARwasundertaken.ThesameSARnotesthattheITsystemheldnorecordofthemanagerhavingagreedactionswiththesocialworker,orofascertainingthatagreedactionshadbeencompleted.Insomecases,discussionofsupervisionofstaffislinkedtothequestionofwhetherstaffpossessedappropriateknowledgeandskills.OneSARcommentsthatthePolicemustensurethatofficersinvestigatingcasesofharmtoanindividualmustpossessknowledgerelevanttothekeyfeaturesofthecaseinquestion.Othersnoteconcernsaboutwhetherstaffhadadequatetrainingininfectioncontrol,possessedsufficientknowledgeaboutpressureulcers,wereconfidentabouthowtorespondtofabricatedillness,orhadbeentrainedindementiacare.Inoneexample,asocialworkerwhodidnotunderstandtheprocessoffinancialappointeeshipfailedtotakeappropriateactiontoinformherself.Here,whilesupervisionwasseenastheresponsibilityofmanagement,practitionerswerealsoexpectedtomonitortheirownknowledgeandseekadvicewherenecessary.Theneedforbettersupportforstaffwasalsorecognised.OneSARacknowledgesthatstaffcanfeelpowerless,anxiousandfrustratedinhigh-riskcases,andanothercommentsontheneedforstafftobesupportedthroughthepressurestofindsuitableplacementsforpeoplewithcomplexandhighriskneeds.Inanothercase,theSARnotesthatstaffarestillstrugglingtocometotermswiththeindividual’sdeath,andyetanotheridentifiestheneedforstafftohavetimeandsupporttoreflectontheirexperience,raisingimportantquestionsabouthowstaffaresupportedtomanagetheimpactoftheirwork.Inafurthercase,carehomestaffwerenotwellsupportedtoobservechangesintheindividual’shealth,andtochallengehealthpractitioners.Inadditiontosupervision,multiagencyhighriskcasepanelswereseentoprovideasignificantsourceofsupportinchallengingcases.

4.2.6. OrganisationalpoliciesTenofthe27SARscommentonorganisationalpolicies.Insomecases,anorganisationhadnotadheredtopolicyorguidance.Inonecase,theannualhealthcheckprocessdidnotcomplywithNICEandRoyalCollegeofGeneralPractitioners’guidelines;carehomestaffdidnotraisedeteriorationinhealthwiththeGP,andequallydidnotchallengechangesinmedicationthataGPmadewithoutseeingtheindividual.Inanother,thehomecareproviderdidnotfollowtheagreedprotocolfornotifyingAdultSocialCareoffailedvisits.

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Inothercases,theconcernisaboutalackof,orunclearpoliciesandguidance.OneSARnotesthatthesafeguardingpoliciesoftheHousingDepartmentwereoutofdate,datingfrombeforetheCareAct2014.AnotherSARcommentsthatpressureulcerguidancewasnotavailableforcarestaff,andthatguidancewasmissingalsoonhowstaffshouldbalanceuserchoicewithadutyofcare.Inanothercase,anunclearcomplaintspolicyledtothelocalauthorityfailingtorespondtoacomplaintfromanindividual’sparents;thisledtotheinvolvementofasolicitor,andultimatelytoaCourtofProtectionapplication.Anotherobservesthatpoliciesfor,andapproachesto,transitionplanningdidnotseemabletoaccommodateacaseofsuchcomplexity,andnoguidancewasavailableforstaffonworkingwithsuiciderisk.Inanothercase,anewapproachtotenancyallocationwascausingconfusionamongstaff,andwasnotfullyembedded;procedureswerestillunderdevelopment.Inafurthercase,theSARnotesalackofguidanceonwhatcanbecommunicatedtorelativesincasesofproviderfailure.Anothernotesthattherecentintroductionofa‘noreply’policy,triggeredwhenaserviceusercouldnotbeseen,wouldhavechangedtheapproachtakentotheindividualinquestionhaditbeenavailableatthetime.Inonecase,organisationalpoliciescompromisedthequalityofaCommunityNursingService:‘weeklyvisits’(inthesenseofonceevery7days)wereconstruedasmeaning‘avisitineveryweek’,potentiallyleavingagapoflongerthan7days.Singlenursevisitsweresometimesscheduledwhenitwasknownthattwonurseswerenecessaryfortheprovisionofcare,careagencystaffwerenotinformedofplannedvisitssocouldnotfacilitateattentiontohisskinbywaitingtodresshimuntilafterthenursevisits,andtheservicelackedasystemforensuringthatallnursesvisitingwereawareofkeycodesthatwouldenableentry.

OneSARmakesthepositivecommentthatassessmenttoolsprovidedforstaffundertheorganisation’sriskassessmentpolicywereflexibleenoughtobeadaptedandusedinlinewithprofessionaljudgementratherthanhavingtobeappliedrigidly

4.2.7. LegalliteracyEightofthe27SARsdrawattentiontotheleveloflegalliteracyshownbytheorganisationsinvolved.Shortcomingsincluded:anabsenceofcarer’sassessment;failuretoidentifytheneedforstatutorysafeguardingresponsibilitiestobecarriedout;failuretoconsideroptionsforimposinginterventionsintheabsenceoftheindividual’sagreement;absenceofknowledgeinbothasocialworkteamandtheclientaffairsdepartmentofalocalauthorityaboutlegalprovisionsforfinancialAppointeesandDeputies,alongsideafailuretoaskforadvice;andpoorunderstandingabouttheIMCAserviceandabouttheneedtoappointanIMCAduringthesafeguardingprocess.Oneexamplepointstowrongadvicegiventoarelativeaboutthepotentialforappealagainstahousingallocationdecision,andabreachofadministrativelawthroughfailingtogivereasonsforthedecision.Inthesamecase,AdultSocialCaredidnotcomplywithlegislationandguidanceontimely,person-centredassessmentofeligibilityforcareandsupport.AnotherSARnotesthatlegalprovisionsintheMentalCapacityAct2005(wilfulneglect),theSeriousCrimeAct2015(coerciveandcontrollingbehaviour)andtheCriminalJustice&CourtsAct2015(wilfulneglectorill-treatment)werepotentiallyrelevantinthecaseinquestionandshouldbeconsidered.Inanotherexample,

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children’sservicesworkerswerenotedtobeunfamiliarwiththeMentalCapacityAct2005andwithself-neglect.

4.2.8. AgencycultureSevenofthe27SARscommentonlearningaboutagencyculture.Inonecase,theSARobservesthatthecarehomewastakinganinstitutionalisedapproachtotheprovisionofcare.Ahousingproviderinanothercasehadacultureofnotproactivelypursuingwithtenantstheirtenancyobligationsregardingthestateofthepremises,makingearlyinterventiondifficult.AnotherSARobservesacultureoflackofcompassionamonghospitalstaff.Inafurthercase,theSARreportsacultureofpooraccountabilityforsocialworkdecisions.Inseveralcases,thecaremanagementmodelforassessmentandmanagementofcareandsupportwasseentobedominant,limitingopportunitiesforlonger-terminvolvementbypractitioners,andresultinginthelocalauthoritymissinginformationaboutchangingcircumstanceswhileacasewasdormantpendingreview.Therewasanabsencetooofaholisticfocusatannualreviewsofcareandsupportplans,whichfocusedoncareandsupportratherthanonoverallhealthandwellbeing.Andinonecase,acultureofproceduralisedpracticeappliedtohousingallocations,limitingconsiderationofmentalhealthandsafeguardingconcerns.Morepositively,alocalauthoritysocialworkteamhadacultureofsupportingpractitionerstoexercisetheirprofessionaljudgement,andacareagencyinthesamecasetookanapproachtostaffallocationthatprioritisedcontinuityofcaretopromoteengagementwithserviceusers.

4.2.9. StaffinglevelsConcernaboutlevelsofstaffingsurfacein6ofthe27SARs.Inonecase,adaughteroftheindividualbelievedthatbecausethecarehomewasshortstaffedtheyhadnotcontactedherwhenhermotherwasunwellshortlybeforeherdeath.TheOccupationalTherapyrecommendationwasthathermothershouldbeturnedduringthenight,buttherequiredhourlycheckshadnotbeencarriedoutonthenighthermotherdied.Inanothercarehomesituation,reducednighttimestaffinglevelsmeantthatanindividualcouldnotbeaccompaniedtohospital.InlocalauthorityAdultSocialCare,reducedstaffinglevelsandahighvolumeofworkresultedinthereferralbeinghandledbyasocialcareassistantratherthanaqualifiedmemberofstaffwhocouldhavecarriedoutamorecomprehensiveriskassessmentofthehomeconditionsandofaninjurysustainedbytheindividual.Inafurthercase,inreferringtoapiecemealapproachbyatenancymanagementservice,theSARpointstotimepressuresthatimpacteduponstaff.Andinrelationtoinvestigationsofpotentialproviderfailure,oneSARidentifiesthatthesewerecompromisedbyrelianceonaverysmallgroupofstaff.

Someobservationsweremadeaboutskilllevelsalso.Inonecase,theSARnotesuncertaintyaboutwhetherthecarehomehadtherightmixofskillstoworkwithanindividual’sbehavior.

4.2.10. MarketfeaturesSixofthe27SARsdrawattentiontomarketfeaturesincareandsupportprovisionthatimpacteduponthecaseunderreview.Theroleofcommissioningandcontractcompliancewasseenascrucial.Inonecase,neitherstaffresponsibleformonitoringcontractsnorthose

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reviewingindividualcasespickeduphowanentrenchedcultureofinstitutionalizationinthecarehomeinfluencedhowresidents’careneedsweremet.Inanother,thefamilyexpressedconcernsthatcontractsbetweenthelocalauthorityandcareproviderswerenotmonitoredadequately,andthatinspectionsofcareproviderswereinsufficientlythorough.Elsewhere,thelocalauthoritydidnotmonitoracareprovider’scontractcompliancewithregardtonotificationoffailedvisits,asituationthatwasexacerbatedbylackoffollowuptocheckthattheservicewasmeetingtheindividual’sneeds.Inafurthercase,theSARcouldnotestablishwhetherrecommendationsfromalocalsafeguardingcaseaudit,relatingtoactionsrequiredbytheAmbulanceService,hospitalandcarehome,hadbeenimplemented.Andinanother,therewerequestionsaboutwhethertheshelteredaccommodationinwhichanindividualwasplacedwascommissionedtoprovidethehighlevelofoversightandsupportheneeded.TwoSARsnoteseriouscommissioninggaps:oneinrelationtoprovisionforyoungpeoplewithcomplexneeds,includinginrelationtomentalhealth,andtheotherinrelationtothe‘requisitevariety’ofprovisionforpeoplewithdementia.AndafurtherSARobservesthattheuseoflongtermblockcontractsincommissioningpracticeencouragesuseofwhathasbeenpaidforratherthanamoreindividualizedselectionofprovidersuitableforanindividual’sspecificneeds.

4.3. Domain3:Interprofessionalandinteragencycollaboration

ThethirddomainoflearningthatemergedfromthecontentoftheSARsrelatestohowprofessionalsandagenciesworkedtogetherinthecasesinquestion.Thethemesinthisdomainare:servicecoordination;communicationandinformation-sharing;sharedrecords;thresholdsforservices;safeguardingliteracyandlegalliteracy.

4.3.1. ServicecoordinationTwentythreeofthe27SARsfoundlearningabouthowtheagenciesinvolvedhadcoordinatedtheirrespectiveinputs.Inmanycases,agenciestendedtoworkonparallellines,lackingajointorsharedapproach,oranysenseofsharedownership.Eachwouldpursueitsownspecialistinputinisolation,sometimesrelativelyshort-term,withoutreferencetoothers.Careplanswerenotsharedoralignedonetotheother.Onoccasionsomeagenciesappearedunawareofpossiblereferralroutestosecuretheinvolvementofothers.Misconceptionsaboutagencyrolesandmutualblamingalsohamperedeffectivecasecoordination.Insomecasesinterventionwasalsodrivenpurelybycrisisresponses,lackingareflectivereviewofcasestrategy.AnumberofSARscommentontheabsenceofinteragency/interprofessionalmeetingsthatcouldhaveprovidedanopportunitytoreflectuponandcoordinateinput,deviseacoherentsetofinterventionsanddevelopsharedriskmanagementstrategies.Intheirabsence,agenciesweresometimesnotevenawareofthelackofsharedfocus.

Inseveralexamples,thelackofsharedstrategymeantthatnooverallpictureofriskwasachieved.Inonecase,itwasunclearwhatcarewasbeingprovidedbywhomandwhen,andtherewasnoclarityaboutwhotookresponsibilityforwhichaspectsofadeterioratingsituation.InanothercasewheretheMARACwasusedtodiscusscomplexcasearrangements,

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onlyrisksrelatingtoantisocialbehaviourandpolicingissueswereconsidered,ratherthanabroadermoreholisticriskfocus.Inafurthercase,amatterforwhichnooneagencywasresponsiblewasnotattendedtoandtheabsenceofsharedconsiderationofoptionsleftopenanunresolvedriskthateventuallycontributedtoafataloutcome.Intwocaseswheremultiagencymeetingswerenotedtohavetakenplace,notallrelevantagencieshadbeeninvited.Inanother,theabsenceofkeypersonnelfromameetingwasnotedintheSARreportasa‘seriousomission’thatlimiteddiscussionoftheindividual’sneeds.Inothercases,arangeofestablishedstructuralmechanismsdesignedtopromotejointworking-suchasmultidisciplinaryteammeetings,continuinghealthcarearrangementsandthecareprogrammeapproach-couldhavebeenusedbutwerenot.WhileanumberofSARscommentthatanyoneagencycouldhavetriggeredamultiagencymeetinginthecaseinquestion,theabsenceofadesignatedagencytoexerciseleadershipincasecoordinationalsodrewcomment.Intwocases,thiswasbelievedtobetheroleofAdultSocialCare,whichwasseeninoneSARastheagencyabletoplacetheindividual’svoiceattheheartofacoordinatedservicestrategy.Inanothercase,theabsenceofcoordinatingresponsibilityresultedinanindividual’sdeteriorationnotbeingsharedwithrelevantagencieswho,intheabsenceofinformationtothecontrary,continuedtheirinputatlevelsthatwereinsufficienttomanagetheadvancingrisks.Inanother,theabsenceofacoordinating/leadpractitionerormanagermeantthatthecomplexityoftheindividual’sneedswasnotrecognisedoraddressed.Andinafurthercaseinvolvinganindividualinhospitalwholackedcapacitytodecidewheretolive,therewasconfusionaboutwhowastheleaddecision-maker;adoctordischargedthepatienthomewhileAdultSocialCarewerearrangingaresidentialplacementinhisbestinterests.Inthiscase,interprofessionalpowerdynamicsmayhavemadeitdifficultforwardstafftochallengeadecisionthatappearedtocontradicttheagreedoutcomefrominterprofessionaldecision-making.

SARsnotetooanabsenceofescalationbetweenagencieswhenconcernswerenotrespondedto.Therewerenumerousexamplesoffeedbacknotbeinggivenaboutactionstakeninrelationtosafeguardingreferrals,theimpactofthiscompoundedbyanabsenceofproactivefollowupbyreferrers,whoconsideredtheirjobdonebymakingthereferral.OneSARnoteanabsenceofescalationroutesthatcouldbeusedincircumstancesofagencydisagreement,leavingmattersunresolved.Failuresofcoordinationbetweenspecificagenciesincluded:• Absenceofjointworkingatthepointofhospitaladmissionbetweenahospitalandsocial

carelearningdisabilityservices;• Delaysincarryingoutacontinuinghealthcareassessment;• LackofcoordinationbetweenAdultSocialCareandHousing;• Lackofco-ordinationbetweenAdultSocialCareandChildren’sServices,anabsenceofa

“thinkfamily”approachtoassessmentofneedsandrisks;• FailuretocontactthePoliceinthelightofpossiblycriminalactionhavingoccurred,and

failuretoreferasuspiciousdeathtothecoroner;• Latereferralsmadetospecialistssuchastissueviabilitynurses;

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• Absenceoffollowupandescalationbythereferringagencywhenreferralsmadewerenotrespondedto;

• Therolesandresponsibilitiesofdifferentprofessionsnotexplainedtothefamily;• AbsenceofjointvisitsbetweenaGPandCommunityNursinginordertofacilitate

treatmentofpressureulcers;• Lackofattentionpaidonhospitaldischargetowhetheracarehomehadthenecessary

equipmentforcatheterflushing,compoundedbyGPdelayinsecuringtheequipment,whichresultedinavoidablehospitaladmissionsfortheindividual;

• Poorhospitaldischargeplanning,showinglackofunderstandingofrolesandresponsibilitiesinrelationtoon-goingcare;

• DisconnectbetweenasafeguardingteamandAdultSocialCare:inonecasetheinvolvementofAdultSocialCarewasseenasareasonnottopursuesafeguarding,butwhereAdultSocialCarepractitionersfocusedoncareandsupportratherthanspecificsafeguardingrisks;intheother,anindividual’sincreasedvulnerabilitynotedaspartofsafeguardingenquiriesdidnotpromptanyreviewoftheircareandsupportneeds;

• Insufficientlyintegratedunderstandingofanindividual’smentalhealth,learningdisabilityandphysicalhealthneeds,withdrugsprescribedformentalhealthhavingadetrimentaleffectonphysicalhealth;

• PoorcoordinationbetweenCAMHSandadultmentalhealthservices;• Absenceofjointcommissioningapproachtocomplexmentalhealthneedsandresultant

placementneeds;• RefusalbyaGPsurgerytoundertakevisitswhenrequestedbyacarehomewhereone

residenthadbeenassaultedbyanother;• Hospitaldischargepressuresonsocialcare,andlackofsharedunderstandingacross

agenciesabouttheprocessofmakingaplacementforsomeonewithdementia,resultinginanunsuitableplacement;

• Failuretoreferanindividualformentalhealthassessmentbecauseofconfusionamongsthealthcarepractitionersastowhowasresponsiblefordoingso;

• Lackofclarityaboutwhoheldoverallresponsibilityformakingdecisionsinrelationtosomeoneinhospitalwholackscapacity(wheretheAdultSocialCare,IMCA-informeddecisiononbestinterestsadmissiontoresidentialcarewasoverturnedbyahospitaldoctorwhodischargedthepatienthome).

Incontrast,oneSARnotesasgoodpracticeamultiagencymeetingheldattheindividual’shouse,theagreedactionsfromwhichwereimplementedswiftly,andevidenceofgoodcoordinationbetweenasocialworkerandanoccupationaltherapist.

Thesegeneralfindingsaboutservicecoordinationwereinmanyexamplesexpandedwithcommentonotheraspectsofworkingtogether:communicationandinformation-sharing,sharedrecords,andthresholdsforservices.

4.3.2. InteragencycommunicationandinformationsharingLearningabouthowagenciessharedinformationwitheachotheremergedin23ofthe27SARs.Reportscommonlynotepoorcommunicationsandanabsenceofsharedinformationacrossawiderangeofagencies:

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• Acarehomedidnotinformhealthcarestaffaboutchangesinanindividual’ssymptomsandinanothercaseacarehomefailedtogivefullandaccurateinformationtoaGP,andagaintoanout-of-hoursGP,whentheybecameconcernedaboutanindividual’shealthandbehaviour,resultinginamisdiagnosis(madeoverthetelephone);

• Informationaboutthepossibilityoftheindividualhavingsustainedaheadinjury,whilerelayedtoHousingandAdultSocialCare,wasnotpassedontotheGP;

• Acarehomedidnotroutinelyprovideatransfersummaryonadmissionofaresidenttohospital;

• AcareagencydidnotpassontoAdultSocialCarecomplaintsaboutthequalityofcarereceivedbytheagencydirectlyfromtheclient;

• Ashelteredhousingproviderwasnotpartytoinformationabouttheextentofanindividual’sneedsatthepointofofferingtenancy;

• Hospitalandcommunityhealthcareteamsdidnotliaisewelltogetheraboutdischargearrangements;

• Ahospitaldidnotcommunicatewellwithacarehomeaboutinfectioncontrolfollowingdischarge;

• AmedicalteamdidnotadviseAdultSocialCareaboutadeteriorationinanindividual’shealththathadimplicationsforhiscareandsupportprovision;

• Policedidnotshareinformationaboutpossiblecoercionandcontrolbyadaughterofhermother,whichmayhavebeeninfluencinghernottoaccepthealthcare;

• Amentalhealthservicedidnotconsulteitherlearningdisabilityservicesorprimarycarewhenreviewinganindividual’smedication;

• Delaysinsharinginformationandtransferringrecordsmeantthatnotallagenciesinvolvedhadagoodunderstandingoftheindividual’sbehaviour;

• Communicationsbetweencarehomestaff,ambulancecrewandhospitalstaffoveranindividual’scareneedsduringadmissiontohospitaldidnotadequatelyconveythestomacarerequired;

• Caseconferenceminutesaspartofasection42investigationwerenotcirculated;• TherewasabreakdownincommunicationbetweenAdultSocialCareandthelocal

authoritydepartmentdealingwithclients’financialaffairsand,inthesamecase,poorcommunicationbetweenthelocalauthorityandtheDWP;

• LackofcommunicationbetweenaGPandAdultSocialCareresultedincrucialmedicalinformationrelatingtomentalcapacitywasnotknowntothesocialworkerundertakingacapacityassessment;

• TherewasnoevidenceofcommunicationwithaCCGtoensureatimelyresponsetoacontinuinghealthcarereferral;

• Informationaboutaresident’shistoryofassaultonotherswasnotsharedwiththesocialworkerofanotherresidentwhobecamethetargetofhisattacks(andinthesamecase,thePolicewerenotinformeduntilafterthe6thattack);

• PoliceandHousing,whoknewanindividualwasdeceased,didnotinformAdultSocialCare,whoweresearchingfortheindividualforthepurposeofasafeguardingenquiryintoanallegedunsafehospitaldischarge;

• Inacaseinvolvingtheclosureofacarehome,differentstrandsofinvestigationhadbeenpursuedintheprecedingmonths–safeguardingenquiriesaboutindividualresidents,CCGnurseassessorsreviewingstandardsofcare,involvementfromcommissioningabout

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contractcompliance,inspectionbyCHC–buttheSARnotesariskthatthesewerenottiedtogethertoallowanoverallpicturetoemerge,andtheimplicationsforotherhomestoberecognised.Equally,theproviderfailureprotocoldidnotresultininformationbeingpassedtothosewhomightneedtotakesafeguardingactioninrelationtoindividualspotentiallyatrisk,suchasotherplacingagenciesandself-fundingresidents.

Whereinformationwasshared,themodeofcommunicationwassometimesnotfullyeffective.Inonecase,familymembersexpressedconcernthatagenciesreliedonpaperandelectroniccommunications,ratherthestafftalkingtoeachother.Inanother,referralsrelayedinformationbutlackedsufficientdetail,includingsignificantfeaturessuchastheseverityofhomeconditions.Onoccasion,sharedinformationdidnotreceivearesponse.

Informationsharingprotocolswerenotedinonecasetobeinsufficientlycomprehensive,failingtoincludeallrelevantagencies.Andinanother,theoperationalisationofprotocolswashamperedbyanabsenceoftrainingandbylackofclarityaboutthecommunication(andifnecessaryescalation)routestobeused.

Thetimingofinformationsharingwasrecognisedascrucialtoo.OneSARemphasisedtheimportanceofearlyinformation-sharingwiththePolicebyagenciessuchastheAmbulanceService,AdultSocialCareandtheHospital,inordernottomissforensicopportunitiesrelatingtoapossiblecrimescene.Inanothercase,amultiagencysafeguardinghubwasunabletoachievefullassessmentandmanagementofriskduetodelayfromsomeagenciesinsharinginformationwiththem.Inafurthercase,delaysinsharingreferralinformationandtheprovisionofinformationthatwasconfusingandambiguousresultedindelaysinallocatingreferrals,leavinganindividualunsupported.

Inanumberofcases,whilerelevantinformationwasheldbydifferentagencies,poorcommunicationmeantthatitwasnotpooledtocreateaholisticoverviewofthecase.Forexample,inonecase,assessmentsbychildren’sserviceswerenotavailabletoAdultSocialCare,healthcareprofessionalswereunawareofconcernsaboutchildneglectandtheGPdidnotreceivealltheinformationobtainedwhenanindividualwithseriousself-neglectwasinhospitalforinvestigations.Andinsomecasesinvolvinginterventionbymultipleagencies,theydidnotroutinelysharewitheachotherinformationabouttheircareplans.Inthreecases,evenwhereinformationwasexchangednomultiagencymeetingstookplace,resultinginanabsenceofsharedunderstandingandaction-planning.Inoneofthecases,thisinhibitedunderstandingoftherepeatpatternsinanindividual’sbehaviour,andthedevelopmentofaviableactionplanwithclearlyassignedrolesandreviewingmechanisms.Inanother,theabsenceofafull,sharedriskassessmentaffectedthedecisionsthatweremade.

SomeSARSincontrastnotelearningfrompositiveexamples.InonecasethisrelatedtohowthePolicehadsharedinformationwithhospitalstaffaboutinvestigationofpossibleneglectbyafriend/carer.Inanother,integratedhealthandsocialcarelocalityteamswereresponsiblefordevelopingcareplansincomplexcases,facilitatingcommunicationbetweendifferentprofessionalsabouttheirrespectiveinput.Inanother,autilitiescompanycommunicatedwellwithahousingprovider,whothenalertedAdultSocialCare.

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4.3.3. SharedrecordsTheextenttowhichagencies’recordswerevisibletoorsharedwithotheragenciesaffectedhoweasilyandefficientlyinformationcouldbeshared.EightSARscommentonproblemsthatarose,eitherwithsystemsthatwereintendedtofacilitaterecordsharing,orwheretheabsenceofsuchasysteminhibitedinteragencycommunication.Thelearningdisabilitypassport,designedtofacilitateinformationsharing,inonecasedidnotcontainrelevantinformation;medicalchangeswereeithernotnoticedornotrecordedbycarehomestaff,andwerethereforenotavailabletomedicalstaff.Inanothercase,thehospitaldischargesummarylackedclarityandcausedconfusionincommunityhealthservicesaboutwhetheranindividualhadactuallybeendischargedandvitalhealthcareprovisionshouldberesumed.Theabsenceofasharedrecordingsystemdrewcomment.OneSARobservesthathospitalandcommunityhealthcarestaffdidnotuseasinglepatientrecordsystem,andanotherthatCommunityNursingandGPrecordswerenotmutuallyvisible.Inafurthercasetheabsenceofacoordinatedrecordingsystemthatcouldbringtogetherallaspectsofanindividual’scaremeantthatpractitionersinonepartofthesystemwereactingwithoutknowingwhatothersweredoing.AnotherSARobservesthattheseparaterecordsystemsofAdultSocialCareandthelocalauthorityclientaffairsteammeantthatfullrelevantinformationwasavailabletoneitherteam.Inafurthercase,theabsenceofacentrallocationinwhichallinformationaboutanindividual’shealthcareneedscouldbeheldmeantthatcarehomestaffwereoperatingwithoutknowledgeofthecontentofthelearningdisabilityhealthcareplan.4.3.4. ThresholdsforservicesDifficultiesarisingfromagencies’thresholdsforaccesstotheirservicesarosein5ofthe27cases.Inonecase,adultsocialcarehadbeenunwillingtoexceedamaximumcarepackageexpenditure.Inanothercase,therewasdisagreementbetweentheCCGandtheHospitalastowhetheranindividualcouldaccessCommunityNursingserviceswhentheywerenotregisteredwithaGP.Inafurthercase,adecisionbyanalcoholservicethatanindividualreferredbyaGPdidnotmeettheircriteriadidnotresultinanyfollow-up.OneSARcommentsoninsufficientflexibilityinthresholdmanagementbymentalhealthservices,indeterminingthatanindividualreferreddidnotmeettheireligibilitycriteria.

4.3.5. SafeguardingliteracyElevenofthe27SARsfoundlearningabouthowagenciesworkedtogetherundersafeguardingprocesses.Inonecase,therewasalackofclaritybetweenagenciesaboutwhetherchannelsofcommunicationwerebeingusedtoconveyinformationundersafeguardingprocedures.Inanother,safeguardingalertsfromtheAmbulanceServicedidnottriggercross-checkswithotheravailableinformationpriortohospitaldischarge.Insomecases,safeguardingconcernswerenotraisedatall,despitehighlevelsofriskandconcern,forexampleabouttheconditionofanindividualadmittedtohospital.Inonecase,tissueviabilityandcommunitynurseshadtorelyoncarehomestafftodescribeanindividual’sskinproblems,astheclientwouldnotallowthemaccess;thisdidnottriggerconcernsorameeting,despitebeingoutsidecarehomestaffroleandcompetence.Inanexampleinvolvingmultipleassaultsbyoneresidentofanother,thefirstassaulthadbeenreportedundersafeguardingbutnotpursued;itwasthennotuntil

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thefifthattackthatafurthersafeguardingreferralwasmade.Eventhen,thePolicewerenotinvitedtothestrategymeeting,andnoclearoutcomestosafeguardthevictimemerged.WhenthePolicebecameinvolvedafterasixthattack,theyconsideredthatthecarehomewasinsufficientlyproactiveinsafeguardingbothresidents,butdidnotescalatethis.

Onoccasion,referralsraisedwerenotfollowedup;severalSARsnotethatfeedbackwasnotgiventothereferrer,andthatreferrersequallydidnotchasewhentheyreceivednofeedback.Inafurthercase,asafeguardalertaboutanunsafehospitaldischargewasinitiallynotpursuedasitwasstatedthattheindividualhadbeenassessedashavingcapacityandhadagreedwiththedischarge.Therewereexamplesinwhichreferralsdidnotleadtoaneffectivesafeguardingplan.Inonecase,althoughpossiblefinancialabusewasinvestigatedundersafeguardingprocedures,thePolicewerenotadvised,andthereforenoconsiderationofpossiblecriminaloffencestookplace.Inonecase,theMARACsystemwasusedtodiscussrisktoanindividual,butnotallagenciesinvolvedwithherwereattendeesatMARACmeetings,andthegroupthereforehadanincompletepicture;awidermultiagencyforumwasneeded.TheMARACalsocloseditsconsiderationofhercasedespiteon-goingsafeguardingrisks.Inanothercasewithinacarehome,thesafeguardinginvestigationdrewonlyonlocalauthorityrecords,anddidnotconsiderinformationabouttheworkundertakenbymentalhealthserviceswiththeindividualwhoposedtherisk.Itemergedalsothatnotallincidentshadbeenreportedbythecarehome,andthateveniftheyhadbeen,thesystemwouldnotnecessarilyhaveidentifiedthattherewasacommonperpetrator,asrecordswereorganisedbynameofvictim.4.3.6. LegalliteracySixofthe27SARscommentuponhowagenciestogethergaveconsiderationtotheuseoflegalrules.Interagencynetworksdidnotalwaysconsidertogetherrelevantpowersanddutiesthatcouldhavebeenofuse.OneSAR,commentingonasituationinwhichanindividualhadtwiceneededsurgery,notestheabsenceofdetailedmentalcapacityassessmentsandsupportedorbestinterestsdecision-making.Anotherquestionsthestatusofanindividual’sadmissiontohospitalintheabsenceofanassessmentofmentalcapacity.Inafurthercase,theinteragencynetworkhadnotconsideredtheuseofstatutorypowerstoimposeinterventioninthefaceofrisktoothers.Inanothercase,nodiscussiontookplacewiththePoliceaboutpossibleoffencesofwilfulneglectandill-treatmentbycareworkersandcareproviders.OneSAR,reviewinginteragencypracticeinthecaseofayoungperson,foundthatthelegalrulesonleavingcareandtransitiontoadultserviceshadnotbeenwellimplementedacrossallagencies.KnowledgeabouttheMentalCapacityAct2005hadbeenvariableacrossagencies,andinherentjurisdictionhadnotbeenconsidered.AndinonecasesafeguardingdutiesundertheCareAct2014werenotwellunderstoodbyallagencies.

4.4. Domain4:SABs’interagencygovernancerole

ThefourthdomainintheanalysisofSARcontentisthatoftheSAB’sinteragencygovernancerole.NineteenSARsrefertoexperiences,challengesandquestionsrelatingtothemanagementandoutcomesofthereviewprocessitselfinthecontentofthereports.Perhapssurprisingly,SARsdonotcommentdirectlyontheadequacyorotherwiseoftheSABproceduresforreviews.Thus,the

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materialinthissectionrelatestotraining,qualityassurance,panelmembership,impactandfamilyinvolvement.

4.4.1. TrainingThreeSARsconcludethatthefindingsshouldbeusedtoreviewtrainingofferedbyoronbehalfoftheSAB,andthenincludedinsubsequentstaffdevelopmentevents.SpecificreferenceinthiscontextismadetotrainingontherequirementsoftheMentalCapacityAct2005,effectiveinformation-sharingandrecord-keepingregardingaperson’shealthandwellbeing,andonhowpracticecanimplementtheprincipleofperson-centredcare.NoneofthereviewsreferredtotrainingforSARpanelmembers,nortosupportforSARcommissionersandreportwriters.Equally,therewasnoreferencetoworkplacedevelopment(Braye,OrrandPreston-Shoot,2013)inordertoensurethatwhatislearnedthroughtrainingcanbeappliedintheorganisationalsystemswithinwhichpractitionersandmanagerswork.

4.4.2. QualityassuranceoftheSARprocessTheWoodreview(2016)criticisesSCRsforbeingofvariablequalityandtheagenciesinvolvedfordefensivenessandforfailingtoensuretimelyoutcomes.SARsdo,however,includeinformationthathasadirectbearingonqualityorofferobservationsonwhatimpactedonithelpfullyornegatively.Thus:

Useofresearch:Onlyaminorityofreportsdrawonresearchevidencetosupporttheiranalysisandcritiqueofthepolicyandpracticethatisbeingreviewed.OnereportcomparespracticewithCQCstandardsrelatingtoperson-centredcare,dignityandrespect,andconsenttotreatment,andanotherdrawsontheevidence-baserelatingtotransition.Severalreportsreferenceavailableresearchrelatingtoadultswhoself-neglect(Braye,OrrandPreston-Shoot,2014)buttheoverwhelmingsenseisofresearchfindingsandotherformsofevidencebeingimplicitratherthanexplicit.Agencyparticipation:Fourreportsspecificallycommentonproblemswithagencyparticipation.ThecommentscentreonlackofqualityassurancebyorganisationsfortheirIMRs,whichwerelongdelayed,notcounter-signedbyseniormanagersand/orpoorinstandard.BesidesanabsenceoftrackingandmanagementinternallyofIMRs,someindividualagenciesarealsocriticisedforinadequateanalysisofpracticeandpolicy,forfailingtoclarifythethinkingbehindpracticeandtoexplainwhypracticewassopoor.OneSAR,troublingly,wonderswhethertheindividualwasseenasalostcause.Thesensethatemergeshereisoflearningopportunitieslostforsomeagenciesandthereviews.AnotherSARobservesthatthereweredifficultiesidentifyingattheoutsetallthepractitionersinvolvedinthecase.However,oneSARstatesexplicitlythattheprocesswasmanagedeffectively.

Defensiveness:TwoSARsspecificallyrefertoreticenceonthepartofsomeorganisationsinvolvedtoengageandtolearnlessons.InoneSARthehomecareagency’sresponsewasdescribedasbriefandasfailingtoaddressalltheissuesrequiredofit.TheSARdoesnotsuggestdefensivenessexplicitlybutdoesstronglyquestiontheintegrityandreliabilityofthisagencyanditsrecords.However,bycontrast,onereportcommentsthatthiswastheSAB’sfirstSARandthepanelapproacheditverymuchasalearningevent,appreciativeofthelearningavailable.AnotherconsideredtheGP’scontributionasverypositive.

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Parallelprocesses:FourSARsdiscussatsomelengthdelayoccasionedbyparallelprocesses.OnereviewfoundthatPoliceinquiriesandCPSdeliberationsdelayedtheSAR,whichwasnotedashavinganegativeimpactonthefamily,oncorrectingweaknessesinservices,andondelayinglearning.Theyconcludethatprotocolswouldhelptoclarifytheinterfacewithseriousincidentinvestigationsandsection42enquiries,andtheiroutcomesshouldbenotedonrelevantcaserecords.Anotheradvisesthattheinvolvementofrelativesshouldbeclarifiedbeforethescopeofreviewisfinalised.TwoSARssuggestthatguidance,similartothatavailabletoLSCBs,wouldbehelpfulinassistingSABstonavigatethroughthedifferentaccountability,investigativeandenquiryprocessesthatcansurroundcases.

Otherreasonsfordelaywerealsobrieflymentioned,includingreviewerunavailabilityanddifficultiesinsettingupinterviews.OneSARnotesaninemonthdelaybetweenanindividual’sdeathandthecommencementofthereviewbutgivesnofurtherdetail.Itdoesobserve,however,thatthedelayandthetimetakentoobtainandmergedetailedchronologiesmeantdifficultyinunderstandingwhythingshappenedastheydid.However,bycontrast,onereviewwascompletedwithintwomonths,thetighttimeframehavingbeenimposedbytheCourtofProtection.Whilstchallengingtomeet,itprovedpossiblebecauseoftheavailabilityofthereviewerandthelimitednumberofagenciesinvolvedinthecase.

4.4.3. MembershipSevenSARsraiseissuesregardingagencyinvolvementinthereviewprocess,includingmembershipofthepaneloverseeingdeliveryofthereport.Threereviewsconcludethatvariousagenciesmustbeinvolvedinthosepanelsorsub-groupstaskedwithdeliveryoftheSAR:NHSEngland,CQCandcarehomeproviderswhenthereareconcernsaboutcarehomeandGPpractice.InafurthertwoSARs,CQCwasnotinvitedtoparticipatedespitethefocusbeingonhospitalsand/orcarehomes.Thiswasnotmentionedineitherreportbutagainraisesthequestionofmembershipofareviewpanel/sub-group,andreferraltoaregulatorwhenthereareconcernsaboutstandards.InoneSARtheAmbulanceServicedeclinedtoparticipateongroundsthatithadparticipatedinthesafeguardingreviewandhadnothingfurthertoadd,andthattheirinvolvementwouldtakestaffawayfromthefrontline.Thoseagencyrepresentativeswithresponsibilityformanagingthereviewprocessconsideredwhethertoinvokethedutytocooperateandthedutytoshareinformationifrequested,containedwithintheCareAct2014,butconcludedthatthisfeltdisproportionateassomeinformationfromtheAmbulanceServicewasavailable.Thecaseraisesthequestionoftheadequacyofthelegalremediesavailablewhenanorganisationrefusestoengageinastatutoryprocess.Italsohighlightstheissueoftherelationshipbetweenthesafeguardingadultreviewandthesection42dutytoenquire.

4.4.4. ImpactTrackingthelonger-termimpactoftheSARsinthissampleisnotpossibleasalltheSARswerecommissionedafterimplementationoftheCareAct2014on1stApril2015andmosthaveonlyrecentlybeencompleted.Nonetheless,thechallengeofdemonstratingimpactmustbeaddressedgiventheWoodReport’scritique(2016)thatlessonshavenotbeenlearnedandindicationsfromSCRsandSARsinvolvingself-neglectthatinsufficientattentionmayhave

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beenpaidtoevaluatingwhathaschangedasaresultofdisseminationofreportfindings(Preston-Shoot,2017).NineSARsaddressthechallengeofdemonstratingimpact.Insomeinstancesthereportnoteshowthereviewhasbeenusedinservicedevelopment–tworecordingtheestablishmentofmulti-agency/highriskpanelsasaresultofaSARtoreinforcemulti-agencyworking;anothertheuseoftheSARininformingservicedevelopmentontransitionandstafftraining;athirdobservingthatlocalauthorityproceduresregardingthemanagementofcomplaintsandthehandlingoflearningdisabledserviceusers’financialaffairshavebeenamended.OnereportdetailschangesthathavebeenmadealreadyasaresultoflearningfromIMRs,withtheSABcontinuingtomonitorhowsuchlearningisimplemented.Changeshereincludedahousing/adultservicespathwayaboutriskofhomelessness,trainingforHousingstaffonsafeguardingandrevisedsafeguardingproceduresinHousing,reviewofHousingallocationpaneldecision-making,andensuringthatpeoplehaveexplicitlyconsentedtotheinvolvementofthirdparties.Anotherreportlistssomechangesalreadymadebyindividualagencies,includingthedevelopmentofcommunicationprotocols,usingexpertiseofotherstaff,anddevelopingacultureofquestioning.Threereportshadanactionplanattached.AnotherofWood’scriticisms(2016)isthatthereviewprocessisflawedbecauserecommendationsareunfocused.Heretheactionswereveryspecific,withtheplantemplateexplicitonlinkingSARfindingsandrecommendationswithananalysisofthecurrentpositionlocally,andthenwithactionstobetaken,bywhom,bywhenandfinallybywhatindicatorsprogresswillbemeasured.Itisofcourseentirelypossiblethatotheractionplansnotsubmittedtothisprojectbutnonethelessinprogressareequallyexplicitandfocused.

TheemphasiswithintherecommendationsonauditandqualityassurancesuggeststhatSABsareverymindfuloftherequirementtodemonstratepracticeimprovementsandservicedevelopmentasSARoutcomes.However,thiswillneedtobefollowedthroughoveralongerperiod.

4.4.5. FamilyinvolvementAsreportedelsewhere(Preston-Shoot,2017),reportsdonotcommentonthereasonsforfamilymembersdecliningoffersofinvolvementinSARsorwhatmightfacilitatetheirinvolvement.However,oneSARdoesrefertotheimpactonfamilymembersofredactedpartsofthesafeguardinginvestigationreport,raisingdoubtsforthemonwhathasnotbeenshared.ThisobservationhasalsobeenfoundinresearchonfamilyparticipationinSCRs(Morris,BrandonandTudor,2015).TheSARadvisesthattheSAB’sSARpolicyshouldaddresssuchconcerns.

4.4.6. OthercommentaryOnereportisunusualinexpressingdistressandangeraboutthefailingsinanindividual’scareacrosstheagenciesreviewingthecase.Anotherreflectsthatsafeguardingsystems,includingreviews,donotadequatelyaccountforsituationsinwhichtheabuserisalsosomeonewithcareandsupportneedsandwheretheyhaveposedriskstoanumberofpeople.Inthiscase,thecarehomerecordsindicatedthattheindividualhadbeeninvolvedin9otherincidents

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arisingfromhisbehaviourwithotherresidents,includingonewherehehadhimselfsustainedbruising.Relativesexpressedconcernthathehadonlyeverbeenseenastheperpetrator,notassomeonewithneedsofhisown.AfterthefinalincidenthewasremovedtothePolicestationandspentthenightthere.

5. RECOMMENDATIONSMADEINTHESARSThissectionpresentsthethemesobservableintherecommendationsgivenintheSARsanalysed,identifyinghowtheseemergefromthelearningaboutthefourdomainsoftheadultsafeguardingsystemexploredabove.

5.1. Recommendationsonmeasurestoimproveandenhancedirectpractice

5.1.1. Person-centred,relationship-basedpractice(10):TenSARsreferspecificallytopromotingthisaspectofpractice,ensuringthatagencyculture,leadershipandtimeallocationsforcasework,forinstanceinAdultSocialCare,empowerpractitionerstobeperson-centredintheirwork.OneSARexplicitlylinksperson-centred,relationship-basedpracticetoMakingSafeguardingPersonal,consideringittobeawholepartnershipresponsibilitytoensurethatperson-centredprinciplesareembeddedinallrelevantpolicies,proceduresandguidance,infrontlinepracticeandinthecommissioningofservices.Anotheradvisesthatpractitionersshouldseekoutthepersonwhoisvulnerableandgaintheirperspective,ratherthanrelyingonlyonfamilymembers.Anotheradvisespractitionerstobecognisantofhumanbias,inthiscasetobeawareofthetendencynottoseeadultpatientswithchildren,fathersespecially,asparents,withtheresultthattheimpactoftheirpoorhealthontheirparentingwasnotprioritised.Thesamecaserecommendsthatfamilydynamicsandhistoricalanalysisshouldbepartofanyassessment.

Providinginformationaboutrelevantprocedures,forexamplerulesforallocationoftenancies,isakeyfoundationstoneforperson-centredpractice.Otherwise,recommendationsadvisepractitionerstoexpressconcernedscepticismandchallengeinordertoengagethepersonindialogueabouttheconsequencesoftheirdecisionsandactions,andtoseektounderstandthemeaningbehindtheperson’shistoryandbehaviours.Indeed,onereviewadvisesthatagenciesshouldclarifytheirambitionsforpeople,specificallythosewithlearningdisabilityandcomplexneeds,toensurethatbestpracticestandardsweremet,includinginvolvementindecisionsandreceivingtherightsupportintherightplaceattherighttime.AnotherrecommendsthattheSABandLSCBshouldexplorewhatmorecouldbedonetoensureperson-centredplanningincomplexcases.

5.1.2. Assessmentandriskassessment(8):EightSARsmakerecommendationsregardingassessment,advisingforinstancethatCareAct2014careandsupportneedsassessmentsshouldbeofferedwhenanindividualrejectsmedical/healthadvice.Self-neglectfeaturesprominentlyhere,withreviewsemphasisingtheneedtoimproveriskassessmentsinsuchcasesandtoensurethatlocalauthoritiescanshowthatsuchcasesarerecognised,assessedandinvestigatedwithoutdelay,withFireandRescueinvolvementwithrespecttofirerisks.Highlightedtooareimprovementsneededtopre-

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admissionassessmentandriskassessmentprocessestoensurechallengingbehavioursandpatternsofbehaviourandariskmanagementplanareidentified.OneSARrecommendsthatknowledgeofcasehistoryshouldbeusedexplicitlytoinformriskassessmentandtoworkwithyoungadultsatriskonself-protectionstrategies.Anotherrecommendsthathigh-riskpanelsshouldensurethatallrisksareidentifiedandriskmanagementplansputinplace,thatthereistimelysupportforcarersandaccesstoGPandprimarycareprovision.

Somereviewsreferenceself-neglectresearch(Braye,OrrandPreston-Shoot,2014)whencommentingthatstandardsofgoodpracticemustbemet.TwoSARsfocusattentionspecificallyonassessmentofnutritionandmalnutritionrisk,recommendingthatSABsseekassurancethatthoseatriskofmalnutritionareidentifiedandworkisundertakentomitigatetherisks.Oneofthesereviewsadvisesaparticularfocusonthosewithdementiaandoncommunicatingriskandidentifyingaccountabilityacrossorganisations(includingondischargefromhospital).ItdrawsonevidencefromanotherSARthatledtoahighlysuccessfulstrategytoidentifyandaddressmalnutritionanddehydrationinadults,suggestingthatthisshouldformthebasisforalocalpilot.

5.1.3. Reviews(3):OneSARrecommendsthatthelocalauthorityshouldensurethattimelyreviewsareundertakenandrecommendationsimplementedfromsafeguardingenquiries.AnotheradvisesAdultSocialCaretoensurethat,whereacaseisnotkeptopenbetweenreviews,therearenonethelessmechanismsformonitoringpotentialchangesinneed.Athirdrecommendsthatreviewsofcomplexhigh-riskcasesmustbecomprehensive,withpreparatorydocumentationfromarangeofsourcesincludingspecialistservices;considerationofmentalcapacityshouldbeapartofallreviews,alongsidehowriskhasbeenassessedandtriangulatedwithinmultidisciplinaryteamsandcareteamssothateveryoneinvolvedisawareofthecurrentassessment.

5.1.4. Involvementoftheindividual,familymembersandcarers(5):TwoSARsremindAdultSocialCareofthedutytooffercarerassessments.Anotherreviewrecommendsthatifthirdpartiesareactingonbehalfofanindividual,agenciesshouldseektheindividual'sconsenttoengagewiththem.Agenciesshouldreviewthirdpartyagreementsifthethirdpartydoesnotrespondtocontactorappearsnottobeactingintheserviceuser’sbestinterests.TwoSARshighlightthechallengeofrespectinganindividual’srighttoprivateandfamilylifealongsidedrawingontheknowledgeandsupportoffamilycarers.Thus,aSABisrecommendedtoseekassurancethatallagenciesarelisteningtoandinvolvingfamilycarersasappropriateinplanningcare.AnothersuggeststhattheSABclarifywhocansaywhattorelativesincircumstancesofanticipatedproviderfailureandconsiderwhatopportunitiesexistfordiscussionaboutrelatives’perceptionsofcarequalityandtheeffectivenessofinformationforrelativesonhowtorecognisegoodcare.

5.1.5. Mentalcapacity(6):Thisaspectofpracticedrawsrecommendationsinsixreviews.TheyfocusonSABspromotingunderstandingacrossallagenciesofmentalcapacity,includingconsiderationofcapacityineverycase,evidencingstatements/assessmentsofcapacity,recognisingthatcapacitycanfluctuateandrecordingthatindividualsareawareoftheimplicationsofunwisedecisions.One

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reviewgivesverydetailedconsiderationtoMentalCapacityActpractice,thekeyelementsbeing:understandingwhenandwhyanassessmentofcapacityiscalledforandhowthismustbecarriedoutandrecorded;supportingpeopletomakeinformeddecisionsandtounderstandtheconsequencesoftheirdecisionmaking(includingunderstandingtherisks);assessingbestinterestsandmakingdecisionsinaperson’sbestinterests;applyingallofthisinbalancingchoiceandprotectionandmakingdecisionsastowhereassertiveactionisrequired;making‘donotattemptresuscitation’decisions;applyingDeprivationofLibertySafeguards.Anotherreviewcommentsexplicitlythatdatesforrepeatmentalcapacityassessmentsmustbesetwherepeopleinhighrisksituationsaredeemedtohavecapacity.Twofurtherreviewsrecommendthedevelopmentofmechanismsforensuringcapacityassessmentsandstrengtheningbestinterestdecision-making,especiallyrecognitionoftheneedforit,whichwaspresentinhospitalservicesbutnotcommunityhealthservicesandthecarehomeinthiscase.

5.1.6. Practicerelatingtopressureulcers(3):OneSARexplicitlyfocusesonpracticeinrelationtopressureulcers.Inthespecificcase,theSABIndependentChairisrecommendedtoliaisewiththreeotherSABswithwhichanNHSTrustisanamedpartner,tohighlightthefindingsofthisreview.TheTrustitselfisadvisedtoanalysethereasonsforanincreasingtrendinhospital-acquiredpressureulcersgrade3and4overthepast12months,thisanalysistobepresentedtothefourSABsalongsidecomparativefiguresfromneighbouringHealthTrusts.AnotherSARgivesverydetailedrecommendationsforindividualagencies,healthcarepractitionersandcarehomeswithrespecttopressureulcers,painmanagement,andtransferstoandfromhospital.AfurtherSARseekstoensurestandardpracticeinfuturewithrespecttowhenpressureulcersandskindamageshouldbereferredintosafeguarding,recommendingthatguidanceisissuedonthispoint.

5.1.7. Accessingspecialistexpertiseandadvice(3):Drawingonarangeofspecialistexpertisemayprovehelpfulwhenseekingtosafeguardadultsfromabuseandneglect.ThreeSARexplicitlyhighlightthisintheirrecommendations,focusingontheroleofLDchampionsinNHSTrustsandtheneedtoreviewoutofhoursaccesstospecialistLDadvice,theavailabilityoflegaladviceinmeetingsdiscussinghighriskcases,andingeneralbringinginspecialistassessmentsorexpertise(forexampletissueviabilitynurse;continenceadviser)toinformmulti-disciplinaryassessments.

5.1.8. Legalliteracy(2):TwoSARsrecommendthatSABsseekreassurance,forexamplefromAdultSocialCareandfromHousingDepartments,regardingstaffknowledgeandunderstandingofrelevantlegalrules.Welfarebenefitsandrights,theresponsibilitiesofAppointeesandtheroleoftheDepartmentofWorkandPensions,theMentalCapacityAct2005,CourtofProtection,andbestinterestdecision-makingallfeaturehere,withconcernsthatstaffknowledgemaynotbeup-to-dateorcompetent.OneemphasisesthatAdultSocialCaremustensurethatresponsestoreferralsandassessmentrequestsaretimelyandcompletedinlinewithstatutoryguidance.

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5.2. Recommendationsonmeasurestostrengthentheorganisationalcontextsinwhichpracticetakesplace

5.2.1. Development,reviewanddisseminationofguidance(14):ArangeofguidanceisrecommendedbySARs,includingforstaffwhenaGPisunknown,ortosupportidentificationofthoseatriskofself-neglectorneglect,tofacilitatelocalpracticeinreducingtheriskofchoking,ortosupportstaffinactingonconcernsaboutchronicnon-engagementthroughthedevelopmentof‘personnotseen’policies.Inacasewherenomulti-agencymeetingswereheldorriskassessmentsconcluded,theSARrecommendsthattheSABdevelopamulti-agencyprotocolforreassessmentofhigh-dependencecareneedsandrisks,usinganagreedneedsandrisksmatrix.Inafurthercase,HospitalTrustsareadvisedtomeetwithresidentialandnursingcarehomestosetoutaprotocolforimprovinghospitaldischargeandadmissiontocaresettings.Elsewhere,housingprovidersarerecommendedtodevelopsafeguardingprocedurestospecifyhowconcernsaboutuninvitedvisitorsshouldberespondedtoandaSABisadvisedtohaveaprocedureonwhatshouldhappenifapersondiesbeforeasection42enquiryhasbeencompleted.DevelopmentofazerotolerancestrategyonviolencefromandbetweencarehomeresidentsisadvisedbyoneSAR,whichalsorecommendsclarificationoftheroleofthepoliceinsafeguarding.Inacaseinvolvingtransitionofalooked-afteryoungperson,theSABandLSCBareadvisedtodevelopaprotocolforthemanagementofsuicidalideationandrisk,andanotherfortransitionplanningforyoungpeoplewithcomplexneeds.

OneSABisadvisedtoconsiderwhetherproviderfailureprotocolsadequatelycovertheneedtoinformotherplacingagencies(andself-funders)aboutriskstoresidents.Anotherisadvisedtoseekreassuranceconcerningamulti-agencyprotocolbetweenHousing,AdultSocialCareandotheragencies,ledbyHousing,regardingassessmentandmeetingtheneedsofvulnerableadultsatriskofhomelessness.

Sometimesthefocusinsteadisuponreviewingandupdatingavailableprotocols,forexampleonself-neglectandoninformation-sharingsothattheycapturethemeaningofadutyofcareintheabsenceofconsenttoshareinformation.Inthesamecase,AdultSocialCareistodeveloprefresherguidanceforstaffonthesupportavailablefromhealthagencies,includingtheNHS111service.OtherSARsrecommendthatproceduresbeupdatedtoencouragestaffacrossagenciestocontactthePolicewhencrimesuchaswilfulneglectissuspected,ortoensurethatearlymulti-agencymeetingsareconvenedincomplexcasesinordertoclarifyinformationheldandtoidentifyresponsiblepersonsfortakingactionsforward.Thus,oneSARrecommendsseveralreviews,namelyofthemanagementofcomplexcaseprocedures,ofescalationprocedurestoseniormanagementtofacilitatecomplexcaseplanning,ofthresholdsforCareAct2014section42enquiriesandsection9assessments,andofeligibilitycriteriaforCAMHSandadultmentalhealthwhereyoungpeopleandyoungadultsarenotfullyengaged.ThesameSARrecommendsareviewofguidance,includingavailablelegaloptions,withrespecttothetensionbetweenself-determinationandadutyofcareinrelationtoyoungpeopleandyoungadultswhoappeartohavecapacitytomakeparticulardecisions.AnotherSARconcludesthatareviewisrequiredofpoliciesandproceduresinrelationtomentalcapacity,bestinterestdecision-makingandadultsafeguardingpathways.

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OneSARgivesdetailedconsiderationtoanexistingriskenablementpolicythatincludesreferencetoworkingwithpeoplewhoarereluctanttoengagewithservices,supportortreatment.ItrecommendsthatthisberevisedtoincludereferencetogoodpracticeinthecontextoftheMentalCapacityAct2005.ItfurtherrecommendsthatAdultSocialCareshouldreviewpracticeguidanceandrecordingformatsforassessment,careplanningandreview,andthathospitaldischargepolicyandpracticeshouldbereviewedtoreflecttheneedforcoordinationandcommunication,drawingonnationalguidancethatisreferencedintheSAR.

5.2.2. Proceduresonreferralandassessmentofneedsandrisks(18):Thefirstlistherefocusesonrecommendationsconcerningprocedurestoimprovepracticeinrespectofreferrals,assessment,careplanningandreview.Someofthe18SARsfocushereonpoliciesandrelatingtoreferrals,asfollows:

• HousingtoreviewitsreferralprotocoltoASC;• Children’sServicesandAdultSocialCaretosharetheirindividualassessmentsroutinelyto

ensureaholisticviewofcases;• NHSTruststorefercasesofsignificantself-neglecttoAdultSocialCare;• NHSTrustsandCCGstoreviewhowpatientsnotregisteredwithGPsmayreceive

healthcareserviceswhenaccesstosuchservicesisnormallyviaaGP;• Clarityaboutreferralpathwaysforcontinuinghealthcareassessment.CCGtoensurethat

aMCAassessmenttoolisusedroutinelybyhealthprovidersandtheindependentcaresector;

• SABtorequireanNHSTrusttodemonstratefailsafearrangementsthatreferralstocommunityhealthservicesarereceivedandactedupon;SABtorequirethelocalauthoritytodemonstratefailsafearrangementsforensuringreferralstodomiciliarycareservicesarereceivedandactedupon;

• Inacasewherestaffdidnotraiseconcernsaboutqualityofcare,thecareprovidertoensureearlierrequestsforcontinuinghealthcareassessmentincasesofhighdependenceneedsanddifficultyprovidingcare,andtoensureescalationwhenthereareCHCassessmentdelaysorconcernsaboutnightstaffinglevelsandabilitytoimplementOTadviceonbestturningpracticeatnight;

• Gatekeepingofreferralstosupportedhousingwithcareschemestoensurethemixofresidentscanbesafelysupported;

• Allagenciestoupdatestaffwithuptodatecontactdetailsforotherkeyagenciesinordertofacilitatesmoothreferralprocesses,withmechanismsalsotoensurefeedbackisgiventoreferringagencies;

• Managementoversightofreferralclosure;• Timelyreferraltopalliativecare;• Clarityontriggersandroutesformultidisciplinarycapacityassessment.

Someofthe18SARsproviderecommendations,additionallyorinstead,onassessmentpracticeitself.Thus:

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• NHSTrustsmusthaverobustprocessesforriskassessmentsincasesofself-harm,self-neglectandsuicidalideation,usingNICEguidanceforguidance.

• Riskassessmentsmustconsiderdepressionandself-neglectwherethereisevidenceofconcernregardingyoungeradults,includingthosewhoarelivingwithothers.

• Thereshouldbeaclearassessmentandservicepathwayforassessmentofcognitiveabilityandcapacityforyoungeradultswhohaveadditionalneeds,forexampleasparentsorcarers.

• ACommunityHealthcareNHSTrustshouldmonitortheprogressionofCHCassessmentsandaddressanydelayswithotherrelevantagencies;theCCGandSABmustensureaprocedureformonitoringthisapproachtoCHCassessments.

• TheSABmustensurethattheLAcanshowthatcasesofself-neglectarerecognised,assessedandinvestigatedwithoutdelay,withproceduresandstandardsofgoodpracticemet,andtheSABshouldarrangewiththeFireServiceforfiresafetyassessmentsofvulnerableadults.

• AHealthTrustshouldensurecommunityhealthcareprofessionalscompleteandsubsequentlyreviewbaselineassessments,usingstandardtools,whenpreviousorpotentialpressuredamageexist,andcompiletreatmentplans.

• Incasesofadultsatrisk,agenciesmustensurethatriskanalysisiscomprehensiveandjointlyagreed.

• Forworkingwithrisk,AdultSocialCareandanNHSTrustmustre-developajointriskenablementpolicythatincorporateslearningfromseveralpubliclyavailableSARs,sothatspecifictoolsareusedforrecordingriskassessmentandriskmanagementinlinewiththenewpolicy/guidance.Theobjectiveforthisreviewistoensurethatkeyassessments,reviewsandchangestoagreedcareplansarerobustlyrecordedandcommunicatedacrossallrelevantagenciessothatallareclearaboutthekeyissuesandrisksandallunderstandtheirrolesandresponsibilities.

5.2.3. Casemanagement(10):Herethefocusisonclarityofarrangements.Thusitisrecommendedthatagenciesshouldknowwhoisresponsibleforcoordinatingchangesinaperson'slife,withsocialworkers/caremanagersespeciallyimportantinco-ordinatingtransitions.FireandRescueservices,alongwithotheragencies,shouldclarifythedesignationofresidentialservicesandshelteredhousingprovision,andthenfullyimplementconsequentdutiesandrequirementsonfiresafety.Managementincarehomesshouldensureoversightofpracticestandards,includingnightchecks,tobedemonstratedthroughsigningoffchecklists.Inothercarehomecases,proceduresshouldbeavailabletoensurethatallunwantedphysicalcontactbetweenresidentstriggersareportandconsiderationofwhetherasafeguardingalertshouldbemade.TheSABshouldconsiderhowtoensurethattheneedsofbothpartiesinanincident(victimandabuserwithcareandsupportneeds)canbeaddressed.

OneSARrecommendsthataleadclinicianshouldbeappointedtooverseecareandtreatmentofhigh-riskpatients,andthatpressureulcermanagementshouldfollowclearpathwaysandguidance,withphotographicevidenceandbodymaps.Inanothercase,aHospiceisencouragedtoensurethatmechanismsareinplacetotriggersafeguardingalertsifapatientraisesconcernsaboutcaretheyhavereceivedpriortoadmission.AnotherSARsuggeststhat

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agenciesshouldnotcloseacasewheretherearesignificantriskstowellbeingwithoutamulti-agencymeetingandthatsupportforyoungpeoplewithcomplexneedsandtheircarersshouldbereviewedinanattempttopreventplacementdisruption.Thesamereviewrecommendsthataleadagencybeappointedincomplexcases,withresponsibilitytoensurethatthereisanactionplanwhererolesareclear.

Elsewhere,oneSARnotesthatjointreviewsoflearningdisabledpeopleandthosewithcomplexneedshadnowbeenagreedbythelocalauthorityandNHSTrusts.AnotherrecommendsthattheSABseekreassurancethatHousinghasreviewedtheworkoftheallocationoftenancydecisionpanelandthatthesixsetlocalcriteriafordecision-makingareadheredtoandthatlettersgivereasonsfordecisions.

5.2.4. Staffingissues:levelsofstaffing;healthandsafety;supervision,supportandtraining:Therearethreeelementstorecommendationshere.Thefirstfocusesonstaffhealthandsafety.TwoSARsmakerecommendationsaboutstaffinglevelsincarehomes,whilstathirdconcentratesonsupportforstaffwhoexperienceaggressionfromresidentsorwhowitnessviolencebetweenresidents.

Thesecondconcentratesonsupervisionandothermechanismsforstaffsupport.Reflectingthediversenatureofthecasesbeingreviewed,therecommendationsherecoverstaffbeingempoweredtoescalateconcernsaboutthedecisionsandactionsofpartneragencies,andencouragedtousereflectionandtheirprofessionaljudgementtochallengedecisionstheyfeelareunsafe.TwoSARsthatfocusonself-neglectrecommendsupportforstafftoimplementrevisedguidanceandsupervisionincaseswhereindividualshavecapacitytotakespecificdecisionsabouttheirhealthandwellbeingbuttherisksofforeseeableharmremainhigh.Sometimestherecommendationsforstaffsupportarespecifictothecontextofthecasebeingreviewed,namelydisputedplacementdecisionsormanagingcareproviderfailure.

OneSARrecommendationsthatsupervisionfilesshouldberetainedforfuturereference,evenafterpractitionersandmanagershavelefttheorganisation.AnotherSARreflectsthecomplexityofadultsafeguardingworkbyrecommendingthatmentalhealthprofessionalsbeavailabletoallstaffforconsultationincomplexcases,andthatlegaladviceshouldbeavailabletomulti-agencymeetingsandtoformalcasereviewsinhigh-riskcases.Itcontinuesthatsupervisionshouldroutinelyconsiderhowtosupportstafftomaintainperson-centredapproachincomplexcaseswheretheperson'sengagementisambivalent.Supportshouldbeavailableforfrontlinestafftomanagetheemotionalimpactoftheworkthroughsupervision,peersupportanddebriefingaftercriticalincidents.AnotherSARpicksupthisthemeofaccesstospecialistsupport.Itrecommendsthatbestinterestdecision-making(theneedforitandhowitistobedone)becoveredinsupervision,andstaffencouragedtoseeksupportandadvicefromspecialistsregardingbestinterests,inthisinstancerelatingtolearningdisability.Thethirdelementistraining.EighteenSARscontaintrainingrecommendations,somehighlyspecificintermsoftargetstaffgrouportopic,somesimplyhighlightinganarea,suchasMentalCapacityAct2005,orrecommendingtrainingtosupportimplementationofrecommendationscontainedintheSAR.Takingtopicsfirst,sevenSARsindividuallyrecommend:

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• SABtoensurethatallstaffareawareofthepoliceroleinsafeguarding,thatviolencefrom

residentsisacriminaloffenceandtheneedtoensureresidentshaveaccesstocriminaljustice.Allstaffmustalsohaveasharedunderstandingofstatutoryadvocacyrequirements;

• SABtoconsiderhowstaffskillsinmanagingchallengingbehaviourinpeoplewithdementiacanbeenhanced;

• SABconsiderhowtoenhancetheeffectivenessofmentalcapacitytraining;• Agenciestoconsiderhowtoincludenightandpart-timestaffintraining;• Trainingtobedeliveredontheimportanceofkeepingrecordsofmeetingsandofbest

interestdecisions,oftransitionsandinformation-sharingabouthowtheseareunfolding,ofupdatedlearningdisabilitypassports,andofobserving,recordingandreportingmedicalissues;

• Trainingtocoverfiveelements,namelystaffawarenessofmechanismsforescalationofconcernswithinandbetweenagencies;guidanceonworkingwithpeoplereluctanttoengagewhererisksarehigh;refreshertrainingonmentalcapacity;guidanceonlegaloptionsinhighriskcaseswheretheadultisassessedashavingmentalcapacity;andpracticedevelopmentsessionsatwhichgoodinteragencypracticecanbeprofiledanddisseminated.

• Trainingtoaddresso lawregardingyoungpeopleandyoungadults,mentalcapacity,mentalhealth,

leavingcare,information-sharingandtransitions;o mentalhealth,complexcaseswhererisksaresignificant,situationswherepeople

aredifficulttoengageandhavecomplexneeds,raisingadultsafeguardingandmentalcapacityissues;

o motivationalinterviewing,assertiveoutreachandauthoritativechallenge;o staffskillsandconfidencetoenquireintoyoungpeople'slivedexperiences,to

recogniseandexploretheimpactofpastexperienceoncurrentengagement,andtoassesstheimpactofon-goingcontactwithfamilymembers.

Otherrecommendationsconcentrateonspecifictargetstaffgroups.Thus,SARsseparatelyrecommended:

• SABtorequireLAtoreviewcontractualarrangementswithproviderstoensureallstaff

aretrainedadequatelyinrequiredactionsfollowingfailedvisits,withfollow-upmonitoring;

• Carehometoensurethatstafftrainingregardingskinintegrityandbedpositioningofresidents;

• Housingtoprovidesafeguardingawarenesstrainingforstaff;ASCtoprovidetrainingonriskassessmentandinformation-gathering;CCGtoprovidetrainingonMCAassessmentsforGPs;

• Trainingofhospitalstaffoncompletionofdeathcertificatesincaseswhereanadultatriskofabuseorneglecthasdied;trainingforhospitalstaff,AmbulanceServicestaffandotheragenciesaboutcontactingthepolicewhenthereareconcernsaboutthedeathofanadultongroundsofabuseorneglect,andoninformingtheCoronerofsuchdeaths;

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• SABtoseekreassuranceabouttrainingprovidedbyanNHSTrusttodoctorsonsafeguardingadults,notingtheyaredifficulttoengagebecauseofshiftpatternsandclinicalresponsibilities;

• Communitynursingstaffandcareprovideragencystafftoreceivebriefingsonsafeguardingrequirements;careprovideragencystafftohavebriefingsonrecognitionandcareofpressuresores,andonperson-centredcareapproaches,includingwhenusingmanualhandlingequipmentandwherecarestaffsharealanguagethatisnotspokenbytheuser;

• Trainingforcarehomestafftoincreasetheirconfidenceindealingwithissuesofsexualityandconsentamongolderresidentswithcapacity,andinassessingandmanagingfirerisks;

• Trainingandstaffawareness-raisingforEmergencyDepartmentstaffinhospitalsregardinglearningdisabilitypatients,especiallythosewithcomplexneeds;

• Trainingtoensurethatpoliceofficershavetheknowledgetoundertakeinvestigationsintoadultsafeguardinganddeathsofindividualsatrisk.

Considerablefaithisinvestedintraining,judgingbythefrequencywithwhichSARsmakerecommendationsofthistype.However,practiceimprovementcanbefrustratedwhereorganisationalstructuresarenotalignedtoenabletheimplementationoflearningacquiredduringtraining,andtrainingtransfercanbedifficulttoachieve(PikeandWilkinson,2013).Afocusnotjustonworkforcedevelopmentbutalsoonworkplacedevelopment(Braye,OrrandPreston-Shoot,2013)ismorerare,butisreflectedperhapsbyoneSARthatrecommendssupportforstafftoimplementitsrecommendationsregardingpracticeonMentalCapacityAct2005assessmentsandDeprivationofLibertySafeguardsprocedures.

5.2.5. Recordinganddatamanagement(17):Heretootherecommendationsarecloselyrelatedtothecasebeingreviewed,withatleastonereviewalsonotingthatindividualagencyactionplanshavefocusedonrecording.Thus:

• Section42enquiriesshouldnoteconcernsaboutacarer’sabilitytocareforothers,for

exampleincasesofself-neglect,withappropriatealertsonITsystems.• GPsshoulddevelopmorerobustsystemforalertswhenpatientsfailtoattendfor

appointmentsordonotdropinastheyusedtodo.• Anindividual’sprogressduringtransitionsshouldberecordedandsuchinformation

shared.• Carehomesshouldensurethatcareplans,riskassessmentsandrecordingareup-to-date,

andthatstaffarefamiliarwithcareplansbymeansofinduction,handoversandcommunication.

• CommunityHealthcareNHSTrustsshouldensurethatdistrictnursingservicescheckemailcommunicationsintheabsenceofhandovercapability.

• AHospitalTrustshouldaddasafeguardingflagtoitsITsystem.• Hospitalsshouldreviewtheirsystemsforhighlightingrepeatadmissions.• Practiceinrespectofthe“CoordinateMyCare”recordshouldbereviewedandreported

backtotheBoard.• ITsystemsshouldbecapableoftriggeringscrutinyofrepeatreferralstosafeguarding,and

anoverviewchronologysheetshouldbeintroducedintoclientrecordsystems.

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• Housingprovidersmustbeabletotrackconcernsaboutthirdpartyproviderservices(forexample,careprovidersorcommunitynursingservices)inordertoescalateifconcernspersist.

• GPrecordsystemsshouldbeabletoshowadherencetoendoflifecarestandardsandrecordingwithincommunitynursingshouldclearlydifferentiatebetweenavisitwherethepatientwasseenandoneinwhichtheywerenot.Equally,itshouldhavethecapacitytoalerttheservicetolongerthannormalgapsbetweenvisitsanditshouldbevisibletobothhospitalandcommunitybasedhealthproviders.

• Accesstoandavailabilityofsharedrecordsshouldbeimproved,andsomemeansconstructedofrecordingriskstatusandsendingcommunicationsabouthighriskacrossagencies,withwaysexploredinwhichasinglecareplancanbedevisedandaccessedbyallinvolved.

• UrgentdiscussionisrequiredwithITsoftwaresupplierstoamendcurrentsystemssothattheybetterfacilitatecaseworkprocessesratherthandrivingthem.

• SABshouldprovideclearguidancetoagenciesonstaffstatements,staffsupportandcollatinginformationafteranadverseevent(thisinthecontextofaworkerwhochangedtheirstoryfollowingleadingquestionsfromamanager).

• ReviewofthetransferofmedicalrecordsbetweenGPsshouldtakeplace.• TheSABshouldreviewaccessbycarehomestafftorecords,especiallyofthelearning

disabilityhealthactionplans.• Allagenciesshoulddevelopsystemsformonitoringnon-engagementincasesofpotential

neglectorself-neglect,andescalatesuchcasestosafeguarding.• Recordsofmeetings,forexampleconcerningchildprotection,shouldenablethosewho

havenotbeenpresenttogainaquickunderstandingoftherisksdiscussedsothattheycanappreciatetheimplicationsfortheirwork.

5.2.6. Commissioning(4):OneSARemphasisestheimportanceofofferingflexibilityinhighrisksituationswhereordinarilyasuddenchangeofproviderwouldbeindicatedduetothecostceilingonspotpurchase.AdultSocialCaremanagementisrecommendedtotakestepstoaddresstheimplicationsofblockcontracts,theconstraintsofwhicharehighlightedintheSAR.AnotherSARadvisesthatcontractmonitoringbycommissioningshouldbebetterconnectedtoindividualassessmentsandcareplansandlessofatick-boxexercise.Thepurposehereappearstobetoensurethatthefocusonindividualsduringthecommissioningprocessisnotlostandalsothat,duringcontractrenegotiationandhandover,considerationisgiventoindividualcareplans.Onemightconsiderthatthisshouldbethepurposeofannualreviews,thoughotherSARs,asreportedabove,haveexpressedconcernabouthowannualreviewsareconducted.Theissuehereisthatthechecksandbalancesbuiltinarenotrobust.

OtherfeaturesofcommissioningarehighlightedbytwoSARs.Inone,commissioningandcontracting,whencontemplatingplacements,arerecommendedtoconsiderhistoricalinformation(onclientrisk)anduseacompatibilitytool(presumablyreferringtocompatibilitywithotherresidents,thoughthisisn'tstated).InanothertheSABisadvisedtoconsiderhowitcaninfluencetheamountandrangeofplacementoptionsforpeoplewithdementiaandhow

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itcaninfluencecommissioningpracticetoensurethatcontractsbuildinarequirementtoadaptfacilitiesandstafftrainingtochangingneedsthroughthelifeofthecontract.

5.3. Recommendationsonmeasurestoimproveinterprofessionalandinteragencycollaboration

5.3.1. Information-sharingandcommunication(10):Onceagain,recommendationsareexplicitinnamingspecificagencieswhereinformation-sharingandcommunicationhastoimprove.Thus,inonecase,aMASHandthePoliceareadvisedtostrengthentheirinformation-sharingbydevelopinganagreedpathwaythatincludesanescalationrouteforanyconcerns.ThesamereviewrecommendsthatallagenciesneedtoempowerstaffintheAmbulanceService,aHospitalTrustandotheragenciestocontactthePolicewhenacrimeissuspected.AnotherreviewfocusesoncommunicationsbetweenrelevantagencieswhenrehousingpeoplewithhighriskandrecommendsasystemforensuringfeedbackbetweenSafeguardingandAdultSocialCareteams.Inathirdcase,GPsarerecommendedtodevelopsystemstoensurecommunicationwithotheragenciesaboutthehealthneedsofindividualpatientsatrisk,andAdultSocialCareisadvisedtoensuremoreeffectivecommunicationwithSafeguardingteams.Afourthcaseagainfocusesoninformation-sharingbythepoliceandalsorecommendsconsiderationofhowaMASHcouldimprovecommunicationsbetweenagenciesandareviewofinformationsharingarrangementsbetweenHousingandAdultSocialCare.

Otherwisethefocusisondevisingmechanismstoensurethatinformationaboutpartiesinsafeguardingincidentsissharedandanalysedacrossagencies,andonensuringthatmulti-agencycommunicationandcollaborationisrobust.HereoneSARrecommendsthedevelopmentofasinglewrittenrecord,availabletothecarehomeandalltheprofessionalsinvolved.ItalsoadvisesontheimportanceofGPsmeetingtosharegoodpracticeaboutworkingwithstaffincarehomestomeetpeople'scomplexhealthcareneeds.AnotheradvisestheSABtoconsiderhowtoensureinformationheldbyapractitionerisdiscussedandanalysedwhentheyhavenotbeenabletoattendamulti-agencymeeting.IndividualSARsalsofocusonhowpractitionersandmanagerscanchallengepracticeanddecision-making,forinstanceregardingskindeterioration,andescalatesafeguardingconcernsacrossagencies.Theyfocustooonhowtoensurethatcommunicationswithinandacrossteamsarerobust,andonhowintegratedservicesatanorganisationallevelcanprovideamorepersonalisedfocusontheindividualthatisresponsivetoriskandneeds,forinstancebybringinghealthactionplansandlocalauthorityreviewstogethersothattheycanplayamorecentralpartinplanningandcoordination.OneSARspecificallyadvisesthattheSABseeksassurancethatthecomplaintsmanagementprocedureisimprovedsothattheresponseistimely,appropriateandattherightlevelwithintheorganisation.

5.3.2. Coordinationofcomplexmultiagencycases(16):Onestrikingthemehereisthefrequencyofrecommendationsaboutbringingallprofessionalsagenciestogethertoshareinformationandplanactionwithrespecttocomplexcases.SixSARsrecommendthedevelopmentorenhancementofsuchamulti-agencyapproach,forexampletoidentifyandmonitorhighriskcases,andtodiscussanddevelopriskmanagementplans,includingcaseswhereindividualsdonotmeetthethresholdforcaremanagement

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services.TwoSARsemphasisetheimportanceofincludingspecificprofessionalswithinthesemeetings,namelyGPsandthePolice.Onereviewalsorecommendsautomaticreferralof'nearmiss'firestoahigh-riskcasemanagementpanel.

OneSARadvisesareviewofexistingforumsandprotocols,includingthecareco-ordinationpolicy,GPpracticeweeklymeetingsandqualitymanagementmeetingsinordertoinformthedevelopmentofanewIntegratedNetworkCoordinationService.Theseforumsare,aspartoftheirprotocol,tomakeexplicitreferencetotherequirementtodealtransparentlywiththesometimescompetinginterestsoftheorganisationsandindividuals.Clearassessmentofneedandrisk,andtheclaritythatflowsfromthatinadvocatingforindividuals,areseenaskeyinfindingarightbalancebetweenanindividual’sneedsandorganisationalconstraints/needs.Thereviewgivesanexampledrawnfromthecaseinquestion,namelyavoidanceofautomaticplacingofpeopleinresidentialcaredirectlyfromhospitalsettingsasaresultsolelyofapolicyaboutcostceilings.Tworeviewsparticularlyfocusontheappointmentofkeyworkerstocoordinateserviceresponses.Othersemphasisetheimportanceofusingexpertise.Thus,inonecase,theSABistoensurethatalcoholservicesrecognisetheirexpertroleinsignpostingindividualstootherprovisionifareferraldoesnotmeettheirspecificcriteria;localauthorityOccupationalTherapistsaretoensurecontinuityofOTsupportforcarehomes,includingpromptprovisionforcarehomesofpersonalhandlingplans.AnotherSARrecommendscloserintegrationofhealthandsocialcareassessmentsinintegratedsettingsandtheneedfornewcasecoordinationarrangementsforhigh-riskindividuals.AdultSocialCarereviewsmustincludeinputfromarangeofagencies.

Anemphasisonimprovingcommunicationandmonitoringcanalsobeseen.Thus,oneSARrecommendsthatthelocalauthoritydevelopatemplateforagenciesforreferralstoCoronersothatthesecanbetracked.Anotheradvisesoftheimportanceofclearlydefinedrolesandresponsibilities,discussionofsignificantevents,cleartransfersummarieswhenapersonisadmittedtohospitalfromacarehomeandcleardischargesummaries.YetanotherrecommendsthattheCCGencourageGPpracticestoidentifyvulnerablepatientsandhighlightthosepatientsforCCGattentionifthepracticeisclosing.Otherwiserecommendationsemergefromthespecificcontextofeachreview.Thus,oneSARrecommendsthattheSABseeksassurancethatsystemshavechanged,especiallyinthelocalauthorityandtheDepartmentofWorkPensions,sothatsimilarfailingsregardingthemanagementofalearningdisabledperson’sfinancialaffairsareunlikelytooccur.AnotherrecommendsthatSABproceduresensureamulti-agencyapproachtotransitionunderpinsworkwithyoungpeopleatriskastheymoveintoadulthood,includingcommunicationandco-operationbetweenChildren’sSocialCareandAdultSocialCare,andchildren’smentalhealthservicesandadultmentalhealthservices.Inanother,theboardistoconsidertheimpactofdiminishedresourcesontheabilityofagenciestoworktogether(inensuringsuitableplacements)(rareacknowledgementoffinancialausterityimpact).Twoothersconsiderhowtostrengthencross-bordercollaborationandencourageacultureofrobustchallenge.Finally,inarareacknowledgementofthemacrocontext,aSARrecommendsthattheSABconsider

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theimpactofdiminishedresourcesontheabilityofagenciestoworktogetherinensuringsuitableplacements.

5.3.3. Hospitaladmissionanddischarge(7):Veryspecificrecommendationsaddressunsatisfactoryhospitaldischargeoutcomes,namely:• Priortodischargehospitalsshouldcheckapatient’sGPregistrationtoensurethat

informationabouttreatmentandon-goingmedicalrequirementshasbeenreceived.• Priortodischargeavailableinformationshouldbecheckedtoascertainwhetherornot

thereareanysafeguardingconcerns.• Toensurethatindividualsarenotleftwithoutservices,NHSTrustsmustdemonstrate

failsafearrangementsthatreferralstocommunityhealthservicesarereceivedandactedupon;thelocalauthoritymustdemonstratesoundarrangementsforliaisonwithrelativeswhenvulnerableadultsaredischarged,andhavefailsafearrangementsforensuringthatreferralstodomiciliarycareservicesarereceivedandactedupon.

• TheCCGmustreviewlocaldischargeplanning;preadmissiontocarehomechecksmustincludethatsufficientmedicationisavailablepriortodischarge;transferlettersforaresidentfromcarehometohospitalmustsetoutdetailsofwhythetransferistakingplaceandhighlightifadmissionistheresultofarepeatconcern.

• Hospitaldischargechecklistsshouldincludemeasurestoensurethatallrelevantagenciesareinformed.

• Supportforadultswithlearningdisabilityandcomplexneedsinhospitalshouldbereviewed,especiallyoutofhourswhenthelearningdisabilityleadnursemaynotbeavailable.

• Hospitaldischargearrangementsshouldbestrengthenedtoensurescrutinyofunforeseenchanges.

5.3.4. Professionalrolesandresponsibilities(7):SevenSARsincluderecommendationshere,withafocusonclarity:howcommunitynursingstaffshouldrespondwhentherearesignificanttissueviabilityissues;theroleofthecommunitymatronoverseeingserviceprovisionwhenseveralhealthcarepractitionersareinvolvedsothatpartneragenciesareenabledtomakeappropriatereferrals;commissionersensuringthatrolesareclearinlearningdisabilityservices.Thethemeofclarityalsoemergesinreminderstostaffabouttheimportanceofstaffpersistenceinchallengingotherprofessionalsandescalatingconcernsaboutindividualandinteragencypractice.Itappearstoointherecommendationthatthoseresponsibleforcoordinatingchangesinaperson'slifeshouldbenamed,withsocialworkers/caremanagersespeciallyimportantincoordinatingtransitions.OneSARrecommendsthattheSABshouldseekreassurancethatAdultSocialCareandNHSTrustsarepromotingpeople’sentitlementtosocialcareassessments,especiallyincasesofself-neglect.Anotherseekstoensurefutureclarityregardingrolesandresponsibilitiesinrespectofcontinuinghealthcareastherewasafailuretoreviewacontinuinghealthcareassessmentwhennecessary.TheCCGistoclarifyCHCreferralprocess,andescalationroutestobeusedwhendelaysaresignificant.OnereviewremindsAdultSocialCarestaffoftheirresponsibilitytoprioritiseadviceandassessmentwhenrequestedbyChildren’sServicesinrelationtoparentsofchildrenatrisk.Finally,seniormanagersare

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remindedoftheimportanceofoversightandscrutinyofspecificissuessuchasintegrationandrecordsharing.

5.4. RecommendationsrelatingtothegovernanceroleoftheSAB

5.4.1. Auditandqualityassurance(17):HereSABsarerecommendedtoconductortocommissionreviewsandcase/fileauditstoseekreassuranceaboutthequalityofprovision.Thefocushasfallenon:

• Annualhealthchecks,toensurethatNICEguidanceisfollowed;• Theimplementationofperson-centredpracticeacrossallpartneragencies;• Complianceofhealthcareprofessionalsregardingpressureulcermanagement;• Complianceandoutcomeofrequiredimprovementsincommunicationbetweenhealth

careagencies/staffandwithfamilymembers;• Carehomepolicyofaccompanyingresidentstohospital;• Existinghospitaldischargepoliciesandpractice;• ThequalityofcareplansprovidedtocareprovidersbyAdultSocialCarecare

management;• Auditofactionbyhousingprovidersonfiresafetyriskassessmentrecommendations,to

provideassuranceonthequalityandthoroughnessofactiontoreducefirerisk;• Auditofsafeguardingrecordsacrossnamedproviderstoensurecompliancewith

standardsofdecision-makingandmanagementoversight;• Communitynursingwithreferencetokeypadaccesstoproperties,clinicalnotes,

recordingofwhetherapatientisseenornot,safeguardingactionplans,andappropriatestaffinglevels;

• HospitalscheckingGPregistrationpriortodischarge;• Howlearningdisabilityhealthandsocialcareteamsworktogether;• UseoftheMentalCapacityAct2005inhighriskandcomplexcases;• Practicewithindividualswithdysphagia;• Mentalhealthsupportforyoungpeople;• Information-sharinganduseofhistoricalinformationonclientspre-admission;• MonitoringinformationfromIMCAserviceproviderstoimproveadvocacyservicesand

ensurethatadvocacyservicesareadequatetomeetneed;• Theeffectivenessofsystemsforplacingpeoplewithdementia;• Howrelativeslocallyperceivethequalityofcare/carehomeswheretheirfamilymembers

areplaced,togetherwiththeeffectivenessofinformationprovidedtorelativesonhowtorecognisegoodcare;

• DataprovisionforaSABonwhethersafecareisbeingprovided;• InformationsharingbetweencommissionersandCQC,inordertoconsiderhowaSABcan

supportcollaborationbetweenthem;• HowpracticemeasuresuptothestandardsinTransformingCare,howwellNHSandsocial

carereviewsarelinkedtogether,howoftenthehistoryofpeoplewithcomplexneedsisconsideredinreviews,andtheroleofthecontractsteaminsharingintelligenceregardingcarehomeprovidersforlearningdisabledadults;

• Safeguardingcasesthatarescreenedout;

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• GovernancearrangementsinNHSTruststoensuretherearenoconflictsofinterestininvestigationsofseriousincidents;

• Hospitaltransportservices(inacasewhereanindividualwasdroppedoffatthewrongaddressandnotseenintotheproperty).

Qualityassurancealsoemergesinrecommendationsforcommissioners.OneSARrecommendsthattheCCGstrengthencontractcompliancewithrespecttoacommunitynursingservice.Anotheradvisesthedevelopmentofguidanceforcontractmonitoringstafftoensureafocusontransitions,person-centredcare,learningdisabilitypassports,mentalcapacityassessmentsandbestinterestandsupporteddecision-making,tofacilitatetheshiftawayfrominstitutionalisedcare.AnotherSARrecommendsthatafocusonpressureulcerworkshouldbesupportedbycommissioningandformakeyfocusincontractmonitoring.ThesamereviewalsorecommendsthattheSABseeksreassurancefromcommissionersthattheyhaveintegratedmentalcapacityassessmentrequirementsintopractice,andthatcommissioningandprocurementwillsupportprovidersinreviewingtheirpracticeregardingassessment,careplanningandreviews.

WhereSARshavefocusedonorganisationalabuse,includingomissionsofcare,recommendationsseektoensuresubsequentgoodpractice.Thus,oneSABisrecommendedtomakeCQCawareofconcernsregardingahomecareprovideragency,andthelocalauthorityistoreviewitscontractualarrangementswiththeprovider.AdultSocialCareandthelocalauthority’squalityassurancedepartmentinanothercasearetoensurepromptproductionofvalidationreportsofcarehome,highlightingrisksandactionplans.OnereviewalsorecommendsthatcarehomesshouldalertAdultSocialCarewhenresidentscomplainandthatcommunicationbetweenAdultSocialCareandcommissioningshouldbestrengthenedregardingservicequality,toincludeanenhancedprotocolforthepanelreviewingplacementsandcarequality,andannualreviewstodrawininformationaboutservicequality.

Recommendationsherearesometimesdirectedtospecificagencies.Thus,themanagementofonecarehomeistoensureoversightofpracticestandards,includingnightchecks,tobedemonstratedthroughsigningoffchecklists,improvedstaffrecruitmentandinduction,andprioritisationofsupervisionandappraisals.Inanothercase,thecarehomeistoauditcareplansweeklyandreviewcareplansmonthly.OnereviewrecommendsthatfireriskassessmentadvicefromtheFireandRescueServicebegiveninwriting.AnothersuggeststhattheSABshouldreviewtherationaleandimpactofthepolicygoalofintegrationbetweenhealthandsocialcareprovision.

TheemphasisonauditandqualityassuranceisdesignedtorealisethebenefitsoftheexternalscrutinythatSARsprovideforfuturelearningandpracticeimprovement.Thus,SARshavebeenconcernedtopromoteorganisationalresilienceindealingwithproviderfailure,learningfromspecificexperience,andtostrengthenadherencetosafeguardingarrangementsandprocedures.Ifrealised,thishelpstoansweroneofWood’scriticisms(2016),namelythatlessonsarenotlearned.

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5.4.2. Awareness-raising(5):Herethefocusissometimesonraisingpublicawareness.Thus,twoSARsrecommendthattheSABshouldencouragepeopletoraiseconcernsaboutisolatedandvulnerableindividuals,includinginstancesofself-neglect,byrefreshingandrecirculatingpublicity,withonealsorecommendingtheraisingofawarenessofeligibilityforadultandcarerassessments.Sometimesthefocusisonpractitioners,withoneSARadvisingthattheSABshouldensurethatthenewlyestablishedcomplexcasepaneliswidelyknownandadequatelyresourced.Anotherfocusesontheprovisionofinformationforfamilies,especiallyregardingcarehomecommissioningandreviews.Sometimesthefocusfallsonbothgroups.AnexamplehereisaSARrecommendingthataSABco-ordinateawareness-raisingacrossorganisations(especiallydomiciliarycareproviderscommissionedbyAdultSocialCare)andforthepubliconpreventionandmanagementofpressureulcers,drawingonnationallyavailablepublicitymaterial.WiththesupportofrelevantHealthprofessionals,thefocusofthecampaignistoinclude:theneedtoidentifyearlysignsandsymptoms;howandwhentoescalateconcerns;whoneedstobeinvolvedwherethereisariskidentified;andlinksbetweenpressureulcersandnutrition/continence/immobility.

5.4.3. ManagementoftheSARprocess:OnereportobservesthatthiswasaSAB’sfirstSARandthatthepanelapproacheditverymuchasalearningevent,appreciativeofthelearningavailable.However,recommendationsrelatingtotheprocessofconductingreviewsreflecttosomedegreethedifficultiesencounteredbySABs,evenwiththedutytoco-operateandthedutytoshareinformationenshrinedintheCareAct2014(Braye,OrrandPreston-Shoot,2015).Nonetheless,recommendationscoveringthisfieldofactivitywerenotcommonlygiveninthereviewsinthissample,reflectingperhapsthatSABsarelearningfromexperienceanddevelopingtheirownprotocols,orperhapsthatfeedbackonSARprocessisgiventoSABsbutnotthroughitsinclusioninthereport.Threetypesofrecommendationsappearunderthiscategory.UseoftheSAR:ThefirstrelatestouseoftheSAR.Heresomerecommendationsarevague,requiringsimplydisseminationoflearning,withoutspecifyingtowhom,forwhatpurpose,orwhen.Othersaremorespecific,suchastheSARthatrecommendsthatlearningfromthecasebeusedasabenchmarkforreviewingon-goingdevelopmentoftransitionservicestoaudithowagenciesarerespondingtoyoungpeoplewithcomplexneeds.Italsorecommendsthatthefindingsofthereviewareusedforalearningandservicedevelopmenteventafteroneyeartoaddresswhathaschangedintheprovisionofservicesforyoungpeoplewithcomplexneedsandwhatremainstobedone.Elsewhere,onerecommendationrequiresaSABtoensurethatthefindingsandoutcomearerecordedonrelevantITsystemswithrespecttotheadultandthecarer.InanothertheSABisencouragedtoengagewiththerelativeregardingtheoutcomeoftheSAR.Athirdrecommendsthedevelopmentofalearningtoolfromthecasetoassistinpracticetransformation.SomeotherreviewsalsorecommendtheuseoftheSARintraining,forexampleonmentalcapacity,information-sharing,escalationofconcernsanddifferenttypesofabuseandneglect.

ManagementoftheSARprocess:ThesecondtypeofSARprocessrecommendationrelatestothemanagementoftheSARprocess.Hererecommendationswereslightlymorenumerous,reflectingthechallengesidentifiedintheearliersectiononSARcharacteristics.ThusoneSAR

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recommendsthedevelopmentofaprocedureforhowdecisionswillbereachedaboutthereviewmethodologytobeused.AnotherSARrecommendsthedevelopmentofaprotocolontheinvolvementofrelatives.Severalmakerecommendationsregardingmembershipofreviewpanels,tosecuretheinvolvementofcarehomemanagers,CQCandNHSEngland.OneSARrecommendsaprotocoltoaddresstheinterfacewithsection42enquiriesandNHSseriousincidentprocessesinordertomaximiselearningandreduceduplication.Interestingly,givencommentsaboveaboutparallelprocesses,thestatutoryguidance(DH,2016)advisesSABstotakeaccountofcoroners’inquiriesandcriminalinvestigationsbuthowtodothisislefttoSABstonegotiate,whereasadvisoryguidancemightprovehelpful.StatutoryguidanceissilentonhowtheinterfacewithNHSseriousincidentprocedures,forexample,mightbehelpfullymanagedalthoughitdoesadvisejointcommissioningwhereanSCR,SARandDHRcouldallbeundertaken.

Therearealsorecommendationsdesignedtosecuremoreeffective-thatismoretimely-constructiveandsoundinvolvementfromagencies.OneSARconcludesthattherewasarangeoflevelsofengagementandtransparency.Itoffersexamplesgoodpracticebutalsoofreticenceeithertolearnlessonsortooffertransparency.Thisitevidencesbytheextenttowhichadditionalinformationhadtobesoughtandanalysed,asitwasnotincludedinIndividualManagementReviewsandthescantactionplanssetoutbysomeorganisations.TheSABIndependentChairisrecommendedtomeetwithrelevantchiefexecutivestoconsiderandaddressthereasonsforthisandtoenhanceengagementinfutureSafeguardingAdultsReviews.Threeothersnamespecificorganisationswhoseco-operationand/orstandardofinformation-sharingwasjudgedinadequateandrequiringimprovement.

Actionplanning:ThethirdtypeofrecommendationonSARprocessrelatestoactionplanning.FromhersampleBestjan(2012)concludedthatrecommendationsandagencyactionplansweresubjecttoregularscrutiny,althoughfewSCRreportshadcommentedonhowlessonslearntwouldbeimplemented,embeddedandmonitored.Braye,OrrandPreston-Shoot(2015)foundrecommendationsrelatingtocreatingandmonitoringactionplans.Suchrecommendationsfeaturerarelyinthepresentsample.OneSARrecommendsthedevelopmentofatemplateforindividualagencyactionplans,theimplementationofwhichshouldthenbemonitored.Anotherrecommendsthatadisseminationstrategyshouldincludeactionplanning,monitoringandreview.

6. INTEGRATIVEDISCUSSIONThissectionprovidescommentaryontheimplicationsofthefindingsreportedinsections3,4and5ofthereport.

6.1. SARQuality

ItisnotpossibletodiscernfromtheSARsthemselveshowSABsapproachedseveralofthequalitymarkers(SCIEandNSPCC,2016;LondonADASS,2017).Forinstance,itisunclearhowandwhyparticularmethodologieswereselectedandtheinfluencethatpreviousSCRsandSARscommissionedlocallymayhavehad.WhenIMRshavebeenthemainfocusofinformation-

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gathering,itisunclearhowthosepractitionersandmanagersdirectlyinvolvedinthecasehavebeenengaged.ReviewsareoftensilentonpanelandSABdiscussionsaboutimprovementactiononcethefindingsandrecommendationswereemerging,withonlyoccasionalcommenttooonhowthereviewprocessitselfwasreviewed.AccesstopanelandSABminuteswouldbenecessarytoanalysedecision-makingregardingpublication,forexamplehowthebalancewasstruckbetweentransparencyandconfidentiality,andtotrackhowlearningfromSARshasbeentranslatedintoservicedevelopment.

Greaterattentioninthereviewscouldbepaidtothereferralitselfandthedeliberativeprocessthatfollowed.Forexample,whoreferredthecaseforpotentialreviewandhowsoonafterthetriggerevent?HowquicklywasthedecisionthentakentogatherinitialinformationfrompartneragenciesandtocommissionaSAR?WasfamilyinvolvementofferedbeforethetermsofreferencefortheSARwereset?Wherefamilymembersdeclinedtoparticipate,whatmighthavebeentheirreasoning?Wherefamilymembers,andalsopractitionersandmanagershavebeenengaged,whathasbeenlearnedfromthisinvolvement,giventhatsuchparticipationisunder-theorisedandinvolvestensionsandchallengesthathavetobeovercome(Morris,BrandonandTudor,2015)?Thosereportsthatincludematerialwrittenorcontributedbyfamilymembersgiveimpactfulvoicetotheindividualandtheirexperience.

Morepositively,thereviewprocessitselfappearstohavebeenmanagedsuccessfully,withcommentgenerallyreservedforwhenchallengeshavebeenencountered,suchasdelaysresultingfrompoorqualityinformationfromagencies,orfromparallelprocesses.Itisnotpossibletoprescribehowtherelationshipbetween,forexample,coronialinquestsandSARsshouldbestruck;however,itmightbehelpfulforSABstodevelopbroadprinciplesforconsiderationatthepointofcommissioningSARs.

Itispossibleinmanyreportstoreadacrossfromfindingstorecommendationsbuttheanalysisoftenlooksinwardsratherthanadditionallyintothewiderpolitical,legalandfinancialcontextswithinwhichpracticeandthemanagementofpracticetakesplace.Arguably,therefore,reviewsdonotaddressallthechallengesandconstraintsthatimpactonsafeguarding(Preston-Shoot,2016).WhereSARsdoaddressresources,aquestionmightbeaskedofSABsastohowwellsightedtheyhavebeenonstaffingandworkloadswithinpartneragencies.WhereSARshighlighttheabsenceofperson-centredwork,morereferencemighthavebeenexpectedtotheimpactofcaremanagementmodelsofpracticeandofperformancemanagementframeworksthatprioritisecaseturnover.

6.2. SARCommissioning

Thesampleof27SARscomprisedreviewsfrom17SABs,withsomeSABshavingcommissionedandcompletedmultipleSARs.Giventhereare30SABsacrossLondon,thisraisesquestionsaboutwhysomeSABs,notwithstandingthatsomemayhaveSARsinprogress,appeartohaveyettocommissionanyreviewssinceimplementationoftheCareAct2014.Thispicture,especiallywhencoupledwithvariationinthenumbercommissionedbydifferentSABs,invitesquestionsaboutthedegreetowhichpartneragenciesareclearaboutthetypesofsituationsthatcouldbereferredforaSAR,andpossiblyabouttheoperationofthresholdsincommissioningdecisions.MorecomprehensivedataonSARreferralstoSABswouldbeneededtoachieveclarificationhere.

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SystematicscrutinyofannualreportswouldalsobenecessarytoreachanyfirmconclusionsaboutthetransparencythatisgiventoSARfindingsandrecommendations,asrequiredbythestatutoryguidance.

6.3. ThemeswithinthecontentoftheSARs

InlinewithpreviousstudiesofSCRsandSARsinLondon(Bestjan,2012;Brusch,2016),thisstudyhasuncoveredsomecommonlyoccurringlearningfromSARscommissionedandcompletedinLondonsinceimplementationoftheCareAct2014.Thesearesummarisedbelow,usingthefourdomainmodeltodemonstratethesystemicnatureofthelearningthatemerges.

6.3.1. DirectpracticewiththeindividualMentalcapacityemergesasacoredimensionoflearningfromtheSARs.Reviewscontinuetouncovermissedopportunitiesformentalcapacityassessmentandbestinterestmeetingsanddecision-making.Assumptionsaremadeaboutindividualshavingcapacityand/orfluctuatingcapacityisnotrecognised.Reviewsalsocontinuetoexpressconcernthatanindividual’sautonomyandself-determinationisprivilegedtotheexclusionofadutyofcare,expressedinrespectfulchallenge,curiosityanddiscussionregardingthatindividual’schoicesandthepotentialconsequencesoftheirdecision-making.TheevidencesuggeststhatpractitionersacrosshealthandwelfareservicescontinuetofindtheMentalCapacityAct2005difficulttounderstandandimplement.

Thepictureonafurthercornerstoneofpractice–assessmentandcareplanning–isequallyconcerning.Examplesarefoundwhereassessmentofneedsandrisksisinsufficientlyrobustorcomprehensive.Caseshereinvolvepressureulcers,peoplewithchallengingbehaviourorerraticengagement,andself-neglect.Therearefailurestorecognisepersistentandescalatingrisks,andattimestheriskmanagementapproachesareinsufficientlyrobustandoutcomeoriented,forexampleinrelationtohospitaladmissionanddischarge,firesafety,missedappointmentsanddeclininghealthandwellbeing.Casereviewpracticeappearsvariable.Makingsafeguardingpersonalisakeyoverarchingprincipleinadultsafeguarding.Yetwhilepracticeisattimesappropriatelypersoncentred,theSARsfoundexamplesofpracticethatisinsensitivetopeople’sneeds,wishesandfeelings,withunmetneeds,poorandinadequatelycommunicatedcareplans,andapparentacceptanceofpoorcarequality.Someagencieshaveinsufficientcontactwiththeindividual,takingothers’assuranceswithoutcheckingtheindividual’sownperspective.Theevidencealsosuggeststhatorganisationsstruggletomeetthechangingandcomplexneedsofindividualswhomayhavecapacitytomakedecisionsabouttheircare:howtomakesafeguardingpersonalwhilstalsoensuringanindividual’sdignityandsafety.Reviewshighlightthedifficultiesofprovidingcarethatbalancesconcernaboutriskwithrightstoautonomousdecision-making.Thiscanresultinanunthinkingadoptionofthenotionoflifestylechoiceandamistakenbeliefthat“thereisnothingwecando”(Braye,OrrandPreston-Shoot,2017),namelythatrespectingsomeone’swishesprecludesanyexplorationofoptionsandalternativepossibilitiestopromotesafetyandtoreducerisk.

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Lookingmorewidelyattheindividual’snetwork,thereisattimesinsufficientengagementwithmembersofthewiderfamily.Thisresultsinlessthanholisticassessmentsofaperson’shistoryandcurrentneeds,andmissedopportunitiestoutilisefamilymembersaspartofprotectionorsupportplans.Carerassessmentsarenotroutinelyofferedandsometimesassumptionsaremade,forexampleaboutconsentforthecarertospeakonbehalfoftheserviceuseroraboutacceptanceoftheirperspectiveofthecaredforperson’shealthandwellbeing.Thereareexamplesofwhereconcernsraisedbyfamilymembershavenotbeenactedupon.Staffknowledgeandskillssometimesappearlackingintwokeyaspectsofpractice–safeguardingliteracyandlegalliteracy.Examplesarefoundwherestafflackedunderstandingofsafeguardingproceedingsandthereforedidnotutiliseavailableprocedurestoprotectindividualsfromharm.Therewereinstanceswheretherewerefailurestoinvokesafeguardingprocedures,forexampleincasesinvolvingpressureulcers,self-neglectandsignificantdeteriorationofresidentsincarehomes.Equally,inanumberofcasespractitionersandmanagersshowedinsufficientfamiliaritywithrelevantlegalrules,andinconsequencefailedtoconsideralltheavailablepowersandduties,includinginherentjurisdiction.

Thenumberofcasesclassifiedasorganisationalabuseorneglectisconcerning.SARshavefocusedonthefailureofagenciestoprovideacceptablestandardsofcareinthecommunityaswellasincarehomesandhospitals.Moreover,theinterfacebetweenthefailuretoprovidegoodqualitycareandsafeguardinghasnotalwaysbeenrecognisedacrossallsectors.

Finally,thereareexamplesofshortcomingsinengagementwithindividualswhomaybereluctanttorespond.Practitionerssometimeslackpersistenceinseekingtobuildthetrustthatcanovercomereluctance,anddemonstratelackofcuriosityaboutthemeaningofanindividual’sbehaviour,failingtolearnaboutsignificanteventsintheirhistory,orlongstandingpatternsofbeliefthataffecttheirpresentsituation.Thequalityoftherelationshipthatcanbebuiltwiththeindividual,throughpersistenceinengagementandanunderstandingoftheirhistory,isacrucialelementofsafeguarding.Importanttooispractitioners’curiosityabouttherelationshipdynamicsbetweenanindividualandothersintheirhouseholdornetwork,withrecognitionofthepowerdynamicsthatmightbeatwork.

6.3.2. OrganisationalcontextforpracticeShortcomingsindirectpracticeareoftenrelatedtothewaysinwhichorganisationalsystems,processes,culturesandconstraintsdirectlyimpactupontheworkofanorganisation’sstaff.

Recordkeepingwasfoundtobeincompletewhereimportanthistoricalinformationwaseithermissingordifficulttolocateinfileswherethechronologywasnotobvious.Recordingisobservedtobeofpoorqualityandunfocused;therationalefordecisionsisnotrecorded,anditisdifficulttodiscernhowsafeguardinghasbeenmadepersonal.Inter-agencysystemsremainincompatibleandsometimesunabletoflagsafeguardingconcerns.Thereviewsshowtheneedforgreatermanagementoversight,forexampleofprotectionplans,investigations,recordkeeping,information-sharing,theneedformultiagencydiscussion,andcaseclosuredecisions.Systemstoalertmanagerstoerrorsandomissions

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appeartobemissing,andmanagersdonotexerciseproactivescrutiny.Equally,proceduresandroutesforescalationtomanagersarenotalwaysclearand/orstaffarenotconfidenttousethem.Supervisionandsupportforstaffissometimesmissing,orfocusesprimarilyoncasemanagementratherthanuponreflectivepractice.Equally,manyofthesituationsencounteredbystaffaredistressing,makingsupportwiththeemotionalimpactoftheworkakeypriority.Supervisionisalsoakeymeansofensuringoversightofstaffcompetence,andofinsertingchecksandbalancesintothemanagementofpractice.Hereagaininthesupervisioncontextthereisanabsenceofattentiontosafeguardingliteracy,andafailuretoconsiderlegaloptionsavailabletotheagency.Staffinsomecasesareworkingwithinadequateresources.Bothservicedemandsandmodelsofpractice,suchascaremanagement,affectthetimeandcontinuityavailabletostafftoundertaketheirworkwithanindividual,andperformancetargetscanprioritisespeedofcaseturnover.Inothercases,specialistplacementsarelacking,increasingthelikelihoodofunsuitableplacements,particularlyatpressurepointslikehospitaldischarge.Inothers,organisationsfailtoensureanadequatemixofsuitablyqualifiedstaff.

AnumberofSARsdemonstratetheimpactofagencyculture,whichcanplaceanemphasissometimesonproceduralisedapproachesthatmilitateagainstcompassionandempathy,ordemonstrateanabsenceoffocusonaccountability.Policiesandproceduresthatareeithermissingorunclear,orarenotembeddedinthepracticeenvironment,furthercompoundthedifficulty.FinallySARsplacethespotlightontheroleofcommissioning,bothintermsofhowservicesarecommissioned,andintermsofhowcontractcomplianceismonitored.Inthecasesinquestion,commissioninggapsexistinrelationtotwokeyelementsofresource–provisionforyoungpeoplewithcomplexneeds,includingmentalhealthneeds,andrequisitevarietyinprovisionforpeoplewithdementia.Inrelationtocontractcompliance,bothBestjan(2012)andthisstudyhavefoundexamplesofthefailureofcommissionedservicestorecogniseandmeetpeople’sneeds,especiallywhereescalatingrisksshouldhavepromptedreassessmentandintervention.

6.3.3. InterprofessionalandinteragencyworkingThefailureofagenciestoworktogetherisarecurringfeatureoftheSARsinthisstudy.Theabsenceofinter-professionalandorganisationalsharingofinformationleadstoincompleteassessmentsofhealthandcareissuesandofoverarchingrisk.Underpinningthiswasoftenmisunderstandingofrolesandresponsibilities,alackofactivereferraltootheragenciesfortheirspecialistexpertisetomeettheidentifiedneeds,andafailuretocoordinatethemultipleparalleltracksonwhichcarewasprovidedbydifferentagencies.Inmanycases,leadershipfromonecoordinatingagencywasabsent,compoundedbyanabsenceofanyeffectivemultiagencydiscussionthatcouldproduceasharedstrategyforintervention.LikeBestjan(2012),thepresentstudyfoundexamplesofcarehomesfailingtoseekadvicefromotherprofessionalsandagenciesinthefaceofchallengesexperiencedinprovidingcare.

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Therewereinstanceswherecriticalinformationwasnotpassedontootheragenciesatthetimeofhospitaladmissionanddischarge.Dischargeplanningwassometimespoorand/orunsafe,policiesandprocedureswerenotfollowed,followuparrangementsdidnothappenandinformationprovidedwasinadequateandincorrect.

Therewerecaseswherepartneragenciesdemonstratedinsufficientknowledgeoftheirresponsibilitiestoreportonormakeasafeguardingreferral.Therewerealsoexampleswhereagenciesdidnotcometogethertodiscusscasesinvolvingsignificantrisksorwhere,whenconferencesornetworkmeetingswereconvened,keyagenciesorpersonnelweremissing.Equally,insomecasesthesafeguardingresponsewasnotadequate.Theneedremainstoimproverecognitionandreportingofadultsafeguardingconcerns,andtoensurerobustresponseswhenconcernsareraised. Legalliteracywasacollectiveomission,withagenciesfailingtoconsidertogetherhowtheirrespectivelegalpowersanddutiescouldinformajointstrategy.Thestudyalsohighlightstheabsenceofprosecutionsforwilfulneglectdespite,inatleastonecase,theevidenceapparentlyavailable.InoneSARnomentionwasmadeaboutavailablelegalroutestoprosecutiondespitepoorpracticeinvolvinginstitutionalisedcareandanabsenceofbestinterestdecision-making.InanotherSARacarerwasnotprosecutedbecausetheywerenotrelatedtotheindividualbeingcaredforandtherewas,therefore,nodirectdutyofcareorformalresponsibility.

6.3.4. SABs’interagencygovernanceroleTheSARsinthisstudyemphasisedtheroleofSABsinpromotingthequalityofSARsbyitssettingofexpectationsaboutcontentandprocess,andbyitsresponsestochallengessuchasdeterminingmembership,dealingwithshortcomingsinagencies’participation,andsettingprinciplesaboutfamilyparticipation.Theirmostcrucialrole,beyondcommissioning,isinensuringthatthelearningthatemergesisusedtoinformactionplansforchange.ThisstudywasnotcommissionedtolookatthisaspectofSARs,buttheextenttowhichSARrecommendationsareturnedintoactionableSABactivityformsthenextmostobviousavenueforfurtherenquiry.

6.4. RecommendationsarisingfromtheSARs

Brusch(2016)inhissmallLondonstudyfoundrecommendationsrelatedtoassessmentandreviewsofneed,riskandmentalcapacity,andtopartnerawarenessoftheirsafeguardingrolesandresponsibilities,forexampleregardingpressureulcersandself-neglect.Recommendationsregardingqualityofprovisionfocusedondignity,escalationofconcernsandthedegreetowhichappropriatecarestandardshadbeenmet,forexampleincarehomesandsurroundinghospitaldischarge.Healsofoundrecommendationsregardingpartnershipworkingandcommunication,withhospitaldischarge,information-sharingandfollowingupreferralsprominent.Therewerealsorecommendationsregardingworkforcecapacity,includingoutofhoursprovision,pathwayplanningandtheneedtoaddresscommissioninggaps.

ThislargerstudyhasfoundSARsconcernedaboutsimilarpracticeissuesandmakingsimilarrecommendations.BothBrusch(2016)andthisstudyhavefoundconsiderablereliancebeing

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placedontraining,thedevelopmentofguidance(forexamplerelatingtocapacityandriskassessments,self-neglectandtissueviability),andaudits(forexampleofmentalcapacityassessmentsandbestinterestdecision-making,recording,hospitaldischargesandpracticewithadultswithcapacitywhoself-neglect).Training,however,islesslikelytogeneratedesiredoutcomesifworkplacesarenotalignedtoenablethosetrainedtoimplementmessagesfromresearchandstandardsofgoodpractice.Similarly,casefileauditsneedtobefollowedupwithhowfindingswillbeusedtotransformthequalityofsafeguardingpractice.SABshavearemittochallengepartneragenciesandtoseekassurancethatlessonshavebeentranslatedintopolicyandpracticedevelopment.Equally,relianceonthedevelopmentoflocalpolicyandpracticeguidancehastobeaccompaniedbyon-goingattentiontothedegreetowhichitisthenembeddedinpracticeandinsupervision.Theredoesappeartobeatrendtowardsfewerrecommendationsregardingthereviewprocessitself(Bestjan,2012;Preston-Shoot,2016).However,thisstudyandearlierresearch(Braye,OrrandPreston-Shoot,2015;Preston-Shoot,2017)wouldsuggestthatSABsshouldgivefurtherconsiderationtowhatmightfacilitatefamilyparticipationandwhatwouldhelpSABpartnersandpanelmemberstodevelopreviewmanagementexpertise,forinstanceaboutmanagingparallelprocesses,selectingproportionateandappropriatemethodologies,andassuringreportquality.

7. CONCLUSIONS

7.1. Therepetitivenatureofthefindingsandrecommendationswithinthissampleandacrossresearchstudies(Bestjan,2012;Braye,OrrandPreston-Shoot,2015;Brusch,2016)suggeststhattherearesystemicstructural,legal,financialandpolicychallengesthataffectpractitionersandmanagersacrossallagenciesandLondonboroughs.Structuralchallengesincludecommissioner-providersplitsandthelackofintegrationbetweenhealthandsocialcare.FinancialchallengesemergewhenSARsfocusontheimpactofresourcesondecision-making,whetherthesizeofcarepackages,delayedassessments,hurrieddischargesfromhospital,socialworkeranddistrictnursingworkloadsorrelianceoninexperiencedstaffincarehomes.

7.2. On-goingconcernsaboutinformation-sharingandaboutcapacityassessmentshighlightthe

challengesthatpractitionersandmanagerscontinuetoencounterwhentryingtounderstandandimplementtheprovisionsoftheDataProtectionAct1998andtheMentalCapacityAct2005.Thefindingsreinforcethepointthat,irrespectiveoftheamountoftrainingprovided,practiceimprovementlocallywillbelimitedwhen,asobservedelsewhere(HouseofLordsSelectCommittee,2014),thelegislationitselfisnotfitforpurpose.Policychallengescomeintheformofstatutorydutiestoconductbothsection42enquiriesandsection44safeguardingadultreviewswithoutstatutoryguidance(DH,2016)consideringtherelationshipbetweenthem.

7.3. WhetherthecircumstancesexploredintheSARsamountedtoadeathorseriousinjurythat

couldhavebeenpreventedremainsanelusivequestion.Bestjan(2012)reportedthat,withinhersample,therewasvariationinreportingwhetherreviewsconsideredthatinjuries/deathsthemselvescouldhavebeenforeseenorprevented.Sheobservedthat,giventheperception

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ofacultureofincreasinglitigation,posingandaddressingthequestionwouldenhanceconsistency,transparency,facilitatesharedlearningandaidanyfuturecomparativeanalysisofreviews.Wherereviewsdidaddressthisissueinhersample,mostreportedthatitwasnotpossibletobedefinitiveaboutwhethereventscouldreasonablyhavebeenanticipatedorprevented,butratherthatagencyactions/inactionswereusuallydeemedcontributoryfactors.

7.4. Inthepresentsample,onlyonereviewdiscusseswhetheradeathwaspreventable.It

concludesthatmoreeffectiveprofessionalcollaborationwouldhavehelped.Itcriticisestheabsenceofadvocacy,multi-agencymeetingsandbestinterestdecision-making.Therewasnocollectiverecognitionthatinterventionwasnotworking.Allofthesesfactorswerepartoffamiliarpatternselsewhere.

7.5. Thisquestionofwhetherreviewsshouldconsiderpreventionisoneillustrationofhowthe

intentionthatSARsshouldprioritiselearningoflessonscannotobscurethefactthatfindingsmaybeusedbyindividualfamilymembersand/orregulatorybodiesforaccountabilitypurposes(Preston-Shoot,2017).Thismaybeonereasonunderlyingpractitionerandorganisationalhesitancy.Establishingpreventabilitymaybetoodifficult,andoflimiteduse.EachSARinthissampledemonstratedauniqueandcomplexpatternofshortcomingsorfailures,eachonitsownunlikelytobesignificantindetermininganoutcome,buttakentogethertheywerefeaturesthataddeduptoa‘faultline’runningthroughthecase;typicallyweaknessesexistedinalllayersofthesystem,fromindividualinteractionthroughtointeragencygovernance,andbeyondtothebroaderpolicyandeconomiccontext.

7.6. Ofmoreuseisthefocusonpreventingfuturesimilarpatternsfromoccurring,anendeavour

dependentonproactiveimplementationofrecommendations.Wood(2016)criticisedSCRsfortheirrepetitiveness.However,asystemicanalysiswouldsuggestthattheproblemliesnotwithSARsandSCRspersebutratherwiththechallengeofimplementingtherecommendations,sincethetransformationofservicesandpracticeenvisagedissometimesbeyondtheresourcesofindividuallocalitiestoachieve.

7.7. Wood(2016)hasalsocriticisedreviewsforafailuretolearnlessons.Bestjan(2012),

however,foundevidencethatreviewshadresultedinproceduralchangeswithinpartneragencies.AlthoughthesewerelargelyinresponsetotheindividualcircumstanceswithinparticularSCRs,theyaddressedissuessuchas:ensuringthatallagenciesparticipateinsafeguardingmeetings;hospitalsreviewrepeatadmissionsandGPsundertakeriskassessmentsfollowingfrequentfalls.SomeSARswithinthesampleforthepresentprojectindicatethatagencieshavealreadybeguntomakechanges,forinstancetohospitaldischargeprocedures,useofmulti-agencypanelsforhighriskcases,liaisonoverfireriskassessment,trainingincarehomesontissueviabilitymanagement,andtheuseoftenancyagreementswithresidentsinsupportedlivingaccommodation.Thus,someevidenceisavailableoftheimpactofindividualSARsonlocalpolicy,proceduresandpractice.

7.8. ConsiderableresourcescontinuetobeinvestedinSARs.Theirfindingsshedlightonpeople’s

livedexperienceofadultsafeguarding,andthecomplexitiesandchallengesinvolved.ResponsibilityfortransformingpolicyandpracticelocallyfallstoindividualSABsandtheir

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individualpartners.However,thelessonsthatemergetravelacrossboundaries,andthereforealsomustinvolveregionalandnationalpolicy-makers.Carefulthoughtthereforeshouldbegiventoensuringthatthewholeadultsafeguardingsystemisengagedinlearning,andthatthedisseminationoflearningpromotesawholesystemcontributiontoservicedevelopment.

8. RECOMMENDATIONS

8.1. ThattheLondonSABconsidersestablishingataskandfinishgrouptoupdatethesectiononSARswithintheLondonMulti-AgencySafeguardingAdultsPolicyandProcedures,withthepurposeofexpandingthequalitymarkerstoprovidemoredetailonthemarkersofagoodqualityreporttoensure:

8.1.1. Thatthereportcontainsclarityon

• Sourceofreferral;• Typeofreviewcommissioned;• Rationaleforselectedmethodology;• Periodunderreview;• Timescaleforcompletion;• Reviewerindependence;

8.1.2. Thatthereportrecordskeydemographicdata,includingethnicity.8.1.3. Thatthereportconcludeswithclear,specificandactionablerecommendationswith

clarityontheagenciestowhichtheyaredirected.8.1.4. ThatSABscomplywithstatutoryguidancerequirementoninclusionofSARdetailsin

annualreportsthatarepublishedinatimelyfashion.8.2. ThattheLondonSABconsidersreviewingandupdatingtheLondonMulti-Agency

SafeguardingAdultsPolicyandProcedureswithrespecttoSARs,therebyrecommendingtoSABsthatthey:

8.2.1. MonitorSARreferralsandtheiroutcomestocheckthatSARsreferredand

commissionedovertimearebroadlyrepresentativeofthepatternofreportedincidenceofformsabuseandneglectinthelocality;

8.2.2. Reviewsafeguardingproceduresandguidancetostaffinthelightofthelearningfromthisreport;

8.2.3. ReviewSARguidanceinthelightofthelearningfromthisreport.8.3. ThattheLondonSABconsidersdisseminationofthisreportto:

8.3.1. TheDepartmentofHealthtoinformpolicyregardingSARs;8.3.2. NationalbodiesrepresentingSABstatutoryandotherpartnerstopromptdialogue

aboutpolicyregardingSARs;8.3.3. Facilitatediscussionandthedevelopmentofguidanceregarding:

• Thresholdsforcommissioningdifferenttypesofreview;• Indicationsforthechoiceofavailablemethodologies;• Managementofparallelprocesses;• TheinterfacewithSCRs,DHRsandMAPPAreviewswhenthecriteriaforsuch

reviewswouldbemetalongsidethoseforaSAR;

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8.4. ThattheLondonSABconsiderscommissioningfurtherstudiestoexplore:

8.4.1. HowthresholdsareforcommissioningSARsarebeinginterpreted;8.4.2. TheimpactandoutcomesofSARscommissionedandcompletedbySABsinLondon;8.4.3. Theadvantagesandlimitationsofdifferentmethodologiesinthelightoflearningfrom

thisreport;

8.5. ThattheLondonSABconsiderswhatsupportitcanprovidetoSABsandtheirstatutorypartnersregardingtheprocessofcommissioning,completingandimplementingthefindingsofSARs,withparticularreferenceto:

8.5.1. Promotingtransparencyinthechoiceofmethodology;8.5.2. Facilitatingtransparencyofinformation-sharingandcandidanalysisinIMRs,panel

discussionsandlearningevents,inordertopromoteserviceandpracticedevelopments;8.5.3. Qualityassuranceoffinalreports.

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REFERENCES

Bestjan,S.(2012)LondonJointImprovementPartnership(JIP):LearningfromSeriousCaseReviewsonaPanLondonBasis.London:LondonJointImprovementPartnership.Braye,S.,Orr,D.andPreston-Shoot,M.(2013)AScopingStudyofWorkforceDevelopmentforSelf-Neglect.Leeds:SkillsforCare.Braye,S.,Orr,D.andPreston-Shoot,M.(2014)Self-NeglectPolicyandPractice:BuildinganEvidenceBaseforAdultSocialCare.London:SocialCareInstituteforExcellence.Braye,S.,Orr,D.andPreston-Shoot,M.(2015)‘Learninglessonsaboutself-neglect?Ananalysisofseriouscasereviews.’JournalofAdultProtection,17(1),3-18.Braye,S.,Orr,D.andPreston-Shoot,M.(2017)‘Autonomyandprotectioninself-neglectwork:theethicalcomplexityofdecision-making’,Ethics&SocialWelfare,http://dx.doi.org/10.1080/17496535.2017.1290814Brusch,S.(2016)SafeguardingAdultsatRiskinLondon–AStocktake.London:NHSEngland(LondonRegion).DepartmentofHealth(2016)CareandSupportStatutoryGuidance:IssuedundertheCareAct2014.London:TheStationeryOffice.HouseofLordsSelectCommittee(2014)MentalCapacityAct2005:Post-LegislativeScrutiny.London:TheStationeryOffice.HullSafeguardingAdultsPartnershipBoard(2014)ADecadeofSerousCaseReviews.Hull:HSAPB.LondonADASS(2017)SafeguardingAdultReviews(SARs)QualityMarkers:SupportingDialogueaboutthePrinciplesofGoodPractice.UnpublisheddraftforLondonSAB.Manthorpe,J.andMartineau,S.(2011)‘SeriouscasereviewsinadultsafeguardinginEngland:ananalysisofasampleofreports.’BritishJournalofSocialWork,41(2),224-241.Morris,K.,Brandon,M.andTudor,P.(2015)‘Rights,responsibilitiesandpragmaticpractice:familyparticipationincasereviews.’ChildAbuseReview,24,198-209.Pike,L.andWilkinson,K.(2013)HowtoGetLearningintoPractice.Dartington:RiPfAPreston-Shoot,M.(2016)‘Towardsexplanationsforthefindingsofseriouscasereviews:understandingwhathappensinself-neglectwork.’JournalofAdultProtection,18(3),131-148.Preston-Shoot,M.(2017)‘OnSelf-NeglectandSafeguardingAdultReviews:DiminishingReturnsorAddingValue?’JournalofAdultProtection,19(2),53-66.

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SCIEandNSPCC(2016)SeriousCaseReviewQualityMarkers.SupportingDialogueaboutthePrinciplesofGoodPracticeandHowtoAchieveThem.London:SocialCareInstituteforExcellenceandNationalSocietyforthePreventionofCrueltytoChildren.Wood,A.(2016)WoodReport.ReviewoftheRoleandFunctionsofLocalSafeguardingChildrenBoards.London:TheStationeryOffice.

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Appendix1:TheanalyticframeworkThenatureandcontentoftheSARswereanalysedusingthedatacollectiontemplatebelow.Manyofthecategoriesusedherecouldformthebasisforsearchtermsifandwhenarepositoryisestablished.CasecharacteristicsA Board FreetextB Casename FreetextC Sex Male

FemaleNotspecified

D Age Under1818-3940-5960-7475+Notspecified

E Ethnicity FreetextF Household Livingalone

LivingwithpartnerLivingwithpartnerandchildrenLivingwithchild/childrenLivingwithparentLivingwithfriendLivingwithprofessionalcarerGrouplivingNotspecifiedOther

G Typeofaccommodation OwneroccupiedPrivatelandlordSociallandlord(standard)Sociallandlord(sheltered)ResidentialcareGrouphomeFosteredHostelHomelessNotspecifiedOther

H Typeofabuse/neglect PhysicalDomesticSexualPsychologicalFinancial/materialModernslaveryDiscriminatoryOrganisationalNeglect/omissionSelf-neglectCombinedNotspecified

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OtherI Outcome Deceased

LifechanginginjuryInjuryFinancial/materiallossOtherNotspecified

J Othercasefeatures FreetextK Circumstances/triggerforreview Freetext

SARcharacteristicsA Sourceofreferral FreetextB Typeofreview Statutory

Non-statutoryLearningreviewPracticereviewThematicreviewOtherNotspecified

C Methodology IMRIMR/chronologybasedSCIEsystemsmodelSILPHybridOtherNotspecified

D Lengthofreport FreetextE Lengthofperiodreviewed FreetextF Subjectinvolvement Yes

NoUnclear

G Familyinvolvement YesNoUnclear

H Publication EntirereportExecutivesummaryBriefingnoteNone

I Referencedinannualreport YesNo

J Commentonchallengesinprocess FreetextK OtherSARcharacteristicsnotlistedabove Freetext

NumberandtypeofrecommendationsA Numberofrecommendations FreetextB Numberofrecommendationsbytype Aboutasingleagency

AboutmultipleagenciesAbouttheSABNational

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Other

ContentofrecommendationsA Practice Person-centred/relationship-based

approachedAssessmentandriskassessmentReviewsInvolvementoftheindividualInvolvementofthefamilyMentalcapacityPressureulcercareAccesstospecialistadviceLegalliteracySafeguardingliteracy

B Organisationalcontext ReferralandassessmentprocessesCasemanagementprocessesStaffinglevelsStafftrainingStaffsupervisionandsupportRecordinganddatamanagementCommissioning

C Interprofessionalandinteragencycollaboration

InformationsharingandcommunicationCoordinationofcomplexcasesHospitaladmissionanddischargeProfessionalrolesandresponsibilities

D GovernanceroleofSAB AuditandqualityassuranceAwarenessraisingManagementoftheSARprocess

SARcontentA Themesrelatingtopractice Mentalcapacity

RiskassessmentMakingsafeguardingpersonalWorkwithfamilymembersHistoryandrelationshipsChallengesofengagementRelationship-basedworkTransition:children’stoadults’servicesViolencetopractitionersSpecialistunderstandingandknowledgeCareplanningAnnualreview

B Themesrelatingtoorganisationalfeatures RecordsandrecordingSafeguardingliteracyManagementoversightResourcesSupervisionandsupportOrganisationalpoliciesLegalliteracyAgencyculture

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StaffinglevelsMarketfeatures

C Themesrelatingtointerprofessionalandinteragencypractice

ServicecoordinationCommunicationandinformationsharingSharedrecordsThresholdsforservicesLegalliteracySafeguardingliteracy

D ThemesrelatingtoSABgovernance TrainingQualityassuranceMembershipImpactFamilyinvolvement

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