5.4 Safeguarding Adults Reviews (SARs)

1. Statutory Framework

The primary legislation governing adult safeguarding, including Safeguarding Adults Reviews (SARs), is the Care Act 2014. The Act mandates that local authorities establish Safeguarding Adults Boards (SABs), which are responsible for arranging SARs under specific circumstances. According to the Act, a SAB must conduct a SAR if:

• an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the individual;
• an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect.

The purpose of these reviews is not to assign blame but to learn from the case to improve future safeguarding practices.

2. Introduction

The Buckinghamshire Safeguarding Adults Board (BSAB) is committed to ensuring that Safeguarding Adults Reviews (SARs) are conducted in line with the statutory requirements set out in the Care Act 2014, the Care and Support Statutory Guidance, and the updated Working Together to Safeguard Children 2023 guidance.

This policy outlines the process for commissioning and conducting SARs, including:

• the Rapid Review process for early learning;
• the requirement from Working Together to Safeguard Children to review the death of a care leaver (aged 18-25);
• the review of deaths of rough sleepers, in recognition of their heightened vulnerability and multi-agency safeguarding responsibilities.

The primary objective of this policy is to ensure that learning from safeguarding incidents leads to systemic improvements and better protection for adults in Buckinghamshire who are experiencing or at risk of abuse or neglect.

3. Purpose of a Safeguarding Adults Review

A SAR must be conducted when:

• an adult in Buckinghamshire dies as a result of abuse or neglect (whether known or suspected) and there is concern that partner agencies could have worked more effectively to protect the individual;
• an adult in Buckinghamshire has experienced serious harm due to abuse or neglect, and there is concern about how local professionals and services worked together;
• a Buckinghamshire care leaver (aged 18-25) dies, whether known or suspected to be from suicide, abuse, or neglect, in line with the Working Together to Safeguard Children 2023 statutory requirement;
• a Buckinghamshire rough sleeper dies, particularly where safeguarding concerns, self-neglect, or multi-agency failures are identified.

A SAR may also be commissioned in other circumstances where it is believed that valuable lessons can be learned.

A Safeguarding Adults Review is not an inquiry into how an adult died or suffered or who is culpable. It is not a reinvestigation of the case, and does not seek to apportion blame or hold individuals to account. There are other processes that exist for these purposes including;

• criminal proceedings;
• disciplinary processes;
• employment law;
• Coroner’s investigation;
• professional regulations such as Care Quality Commission, Nursing and Midwifery Council, Health and Care Professions Council and the General Medical Council.

It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain the maximum benefit from them. If individuals and their organisations are fearful of Safeguarding Adult Reviews, their response will be defensive, and their participation guarded and partial.

It is acknowledged that organisations will have their own internal/statutory review processes for investigating serious incidents and Safeguarding Adult Reviews are not there to replace those processes. Such reviews/investigations can be used alongside and contribute to a Safeguarding Adults Review and can be considered as an alternative option for reviewing a case should a request for a Safeguarding Adults Review not be deemed to meet the criteria, but it is felt that something can be learned.

If the Buckinghamshire Safeguarding Adults Board decides to conduct a Safeguarding Adults Review where another local authority is involved, the chair of Buckinghamshire Safeguarding Adults Board will inform the chair of that authority’s Safeguarding Adults Board. Together they must agree whether the Safeguarding Adults Review should be conducted as:

a) a Buckinghamshire Safeguarding Adults Board review with input from the other Safeguarding Adults Board; or

b) a joint review where members of each panel work together as an expanded panel.

This decision will depend on the complexity of the case and the degree of involvement of each partnership. Should the chairs be unable to agree, the matter must be referred to the respective chief executives for a decision, or failing that to the Care Quality Commission.

4. Special Considerations for Care Leavers and Rough Sleepers

4.1 Care leavers (Working Together to Safeguard Children 2023 requirement)

In line with Working Together to Safeguard Children 2023, the death of a care leaver (aged 18-25) must be considered for a SAR, particularly where:

• the death is linked to suicide, abuse, neglect, or multi-agency failings;
• the individual had recent or ongoing engagement with leaving care services, social care, or mental health support;
• there are concerns about the transition from children to adult services.

4.2 Rough sleepers

To ensure effective learning and systemic improvement, multi-agency responses to homelessness, mental health, and safeguarding responsibilities will be closely examined in SARs involving rough sleepers

The death of a rough sleeper may trigger a discretionary SAR, known as Homeless Mortality Review especially when:

• there are indications of self-neglect, exploitation, or abuse;
• multi-agency involvement was inconsistent, ineffective, or absent; or
• there were known safeguarding concerns but insufficient interventions.

5. Links with other Reviews

There are separate statutory review requirements for domestic abuse related death reviews (see Domestic Homicide Reviews, Buckinghamshire Council) and Child Safeguarding Practice Reviews which are carried out for serious child safeguarding cases. There will be circumstances where a Safeguarding Adults Review and a Domestic Homicide Review or Child Safeguarding Practice Review is required because they concern the same source of risk etc.

Consideration should be given to how the processes can be managed in parallel in the most effective manner to enable organisations and professionals to learn from the case. This could involve joint arrangements for some aspects of the review or a joint review with key lines of enquiry relevant to the Safeguarding Adults Review.

When the criteria is met for more than one type of review, the SAB will engage with the chair of the other relevant board to determine which review is most appropriate and whether more than one type of review is required.

6. Coroner’s Inquests

A coroner’s court is a legal body that helps to determine how, when and why a person died, but not who is responsible. The investigation is held in public at a coroner’s court where:

• a death was sudden, violent or unnatural; or
• a death occurred in prison, police custody or whilst the person was subject Deprivation of Liberty authorisation; or
• the cause of death is still unknown after a post-mortem.

A Safeguarding Adults Review must take into account of any coroner’s inquiry or criminal investigation related to the case to ensure that the relevant information can be shared without incurring significant delay in the review process. The Chair of the subgroup will liaise with the coroner regarding any relevant Safeguarding Adults Review referrals.

When the coroner has decided that an inquest will be held on a case where a SAR is taking place, relevant information should be shared. The Chair of the subgroup will share the draft or final overview report with the coroner in order to contribute to the inquiry.

7. Principles of a Safeguarding Adult Review

Safeguarding Adults Reviews should reflect the six safeguarding principles of empowerment, prevention, proportionality, protection, partnership and accountability (see Principles of Adult Safeguarding). Safeguarding Adults Reviews should also be person centred and reflect the making safeguarding personal approach embedded in the Care Act 2014 (see Making Safeguarding Personal).

Buckinghamshire Safeguarding Adults Board and partner organisations should also apply the following principles when carrying out all reviews.

• the adult with care and support needs should be supported to be involved in the Safeguarding Adults Review and advocacy should be arranged if required (see Independent Advocacy);
• families should be invited to contribute to reviews. They should understand how they are going to be involved, and their expectations should be managed appropriately and sensitively;
• the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
• professionals should be involved fully in the reviews and invited to contribute their perspectives without fear of being blamed for actions which they took in good faith;
• there should be continuous learning throughout the whole process and actions should be put into place as identified not just at the formal end of the process;
• Buckinghamshire Safeguarding Adults Board is responsible for making sure that the Safeguarding Adults Review takes place in timely manner and seek assurance of the completion of the appropriate improvement action.

8. Process for Commissioning and Conducting a SAR

8.1 Making a Referral for a Safeguarding Adults Review

Buckinghamshire Safeguarding Adults Board is the only body which can commission a Safeguarding Adults Review within Buckinghamshire. There is no restriction as to who can submit a referral for a Safeguarding Adults Review. It is generally expected that any referral is discussed and agreed with the agency safeguarding lead prior to submission but this is not essential.

Referrals should be submitted using ‘Form B – Referral for a Safeguarding Adults Review‘ (opens in Word). The referral document should be submitted as soon as the Safeguarding Adults Review criteria appear to have been met. The referrer should provide all relevant available information. It is important to note all the agencies that are known to have been involved in the case, as this will enable further scoping to be undertaken.

Completed referral forms should be sent to the Chair of the Safeguarding Adults Review subgroup via the Safeguarding Partnership Manager. Referrals can be made via email to [email protected]

8.2 Screening the Referral

On receipt of the referral this should be initially placed on the Safeguarding Adults Review log held within the Business Unit. At the discretion of the Chair of the Safeguarding Adults Review subgroup, an electronic notification will be sent to all subgroup members alerting them to the potential for a Safeguarding Adults Review.  Members will confirm receipt of this notification and make arrangements for all relevant records within their organisation to be identified and sealed if decided this is appropriate

All new referrals will be reviewed through a Rapid Review panel made up of the three statutory partners (local authority, health and police) and key relevant agencies. They will be supported by the Safeguarding Partnership Manager whose responsibility it will be to convene the Rapid Review panel. The decision on whether the SAR criteria is met can only be made by the three statutory partners. The process however should aim for a consensus, not a majority view. As the SAR is a multiagency review, there is a need for all the agencies to sign up to the review taking place and embedding the learning

8.3 Rapid Review Process

A Rapid Review is conducted as a way of providing a swift multi-agency analysis to determine key themes, immediate safeguarding improvements, and whether a full SAR or an alternative learning review is required.

Process to follow (completed within 15 working days)

• upon receipt of a SAR referral, the SAR Subgroup will determine whether a Rapid Review is necessary;
• if agreed, all relevant agencies must submit a chronology and summary of their involvement within 5 working days;
• a multi-agency Rapid Review meeting will be held within 10 working days to:
  • identify immediate safeguarding concerns;
  • determine whether the case meets SAR criteria (see Section 3);
  • make recommendations for further review or action.
• a Rapid Review summary report will be completed within 15 working days and submitted to the BSAB for consideration.
• if a full SAR is required, the standard commissioning process will follow;
• if no SAR is required, the case may be referred for an alternative Learning Review or Multi-Agency Case Audit.

Once the panel have reached a final decision this will need to be ratified by the Independent Chair for the Safeguarding Adults Board. This decision will also be communicated to the Safeguarding Adults Board SAR subgroup and the individual/agency submitting the referral.

The recommendation of the Safeguarding Adults Review subgroup must be forwarded to the chair of the Buckinghamshire Safeguarding Adults Board, who has ultimate responsibility for deciding whether or not to conduct the review.

If the decision is to proceed, the Safeguarding Adults Review subgroup will then commission the review and request that a Panel be formed, with the chair for the Panel ideally identified as an existing member of the SAR subgroup. However, should a different approach be identified, then a member of staff from another agency might be able to chair the Review Panel.

At the same time a letter will be sent to the referrer informing them of the outcome of the referral as well as letters notifying the adult and or family of the outcome of the referral and a leaflet explaining the process of a Safeguarding Adults Review.

Members of the Review Panel have a dual role; to represent professional or organisational views in relation to information brought before the Safeguarding Adults Review subgroup and to act collectively in representing well-evidenced, best practice standards.

Each Review Panel must therefore also consider co-opting additional representatives to ensure that each review is informed and directed by those deemed relevant to each case.

In selecting representatives each agency must choose someone who:

• is able and has an explicit mandate to represent the organisation’s views, policies and practice appropriately;
• has sufficient experience and knowledge of the field to inform the debate and the matters under consideration, and
  • is of sufficient authority or seniority to ensure that recommendations arising from the review are addressed within their agency;
  • as not been involved directly in working with or managing the case being reviewed;
  • will be able to commit the time necessary to contribute to the review.

8.4 Appeals Against the Decision

If any Buckinghamshire Safeguarding Board member, involved agency or person disagrees with the decision made on behalf of the Board following a referral for a Safeguarding Adults Review, then an appeal against that decision can be made. The appeal should be made in writing to the Chair of the Board via the Safeguarding Partnership Manager. The appeal should include the rationale for undertaking the review and any additional information relating to the case.

Following receipt of the appeal, the Chair of the Board and another member of the Board will review the decision and a response to the appeal will be made by letter.

A complaint can also be made to the Councils’ Complaints department and ultimately to the Local Government and Social Care Ombudsman.

9. Conducting a Safeguarding Adults Review

When a case has been approved by the Safeguarding Adults Review Subgroup, a Lead Reviewer will be sourced. This process will be overseen by the Safeguarding Partnership Manager with a view to being more transparent and ensuring an open process takes place. The Safeguarding Partnership Manager will source up to three potential Lead Reviewers for the SAR and present them to the SAR Panel. The Panel will then be responsible for selecting the Lead Reviewer that they will work with throughout the SAR process. The Lead Reviewer will meet with the Panel to start to draw up the Terms of Reference for the review as well as identifying with the Panel members any issues of relevance. Issues to consider may include:

• when should the review process start and by what date should it be completed? N.B. The target for each review should be for completion of a Safeguarding Adults Review within 6 months of initiating it.
• how the adult who is the subject of the review and/or family members/carers should contribute to the review, and who should facilitate their involvement? What are the most important issues to address in trying to learn from this specific case? How can the relevant information best be obtained and analysed?
• is the process proposed by the subgroup still the right process?
• are there features of the case which indicate that any part of the review process should involve, or be conducted by, a party independent of the professionals/organisations that need to participate in the review?
• would it help the review panel to bring in an outside expert at any stage to shed light on crucial aspects of the case?
• how are the adult and or their family going to be involved in the process?
• over what time period should events be reviewed, i.e. how far back should enquiries go, and what is the cut-off point?
• what family history/background information will help to better understand the present?
• which organisations and professionals should contribute to the review?
• is there a need to involve organisations/professionals in other SAB areas, and what should be the respective roles and responsibilities of other SAB’s with an interest?
• how should the Safeguarding Adults Review process take account of a coroner’s inquiry, and any criminal investigations or proceedings related to the case? Seek advice from police regarding potential conflict with ongoing police investigation.
• what is the best way to liaise with the coroner and/or the Crown Prosecution Service?
• how should the review process fit in with other reviews?
• who will make the link with relevant interests outside the main statutory organisations e.g. independent professionals and voluntary organisations?
• when should the review process start and by what date should it be completed?
• how should any public, family and media interest be handled, before, during, and after the review?
• does Buckinghamshire Safeguarding Adults Board need to obtain independent legal advice about any aspect of the proposed review?

Some of these issues may need to be revisited as the review progresses and new information emerges.

More than one Reviewer may be commissioned if the SAR in question requires a range of expertise beyond the scope of one Reviewer. If this is the case, one of the Reviewers commissioned will be designated the Lead Reviewer and will prepare the final written SAR report.

10. Timescales

Reviews will vary widely in breadth and complexity. In all cases, lessons should be learned and acted upon as quickly as possible.

Reviews should be completed within six months, unless an alternative timescale is agreed.

Sometimes the complexity of a case does not become apparent until the review is in progress.  As soon as it emerges a review cannot be completed within six months of the chair’s decision to initiate it, the chair of the Buckinghamshire Safeguarding Adults Board must agree a timescale for completion.

In some cases, criminal proceedings may follow the death or serious injury of a adult.  Those co-ordinating the review should discuss with the relevant criminal justice agencies how the review process should take account of such proceedings e.g. how does this affect timing, the way in which the review is conducted (including interviews of relevant personnel), who should contribute and at what stage?

Safeguarding Adults Reviews should not be delayed as a matter of course because of outstanding criminal proceedings or an outstanding decision on whether or not to prosecute.  However, the views of the police and crown prosecution service should always be sought.

In some cases, it may not be possible to complete or to publish a review until after coroner or criminal proceedings have been concluded, but this should not prevent early lessons from being implemented.

11. Who should be Involved in the Safeguarding Adults Review?

Initial scoping of the review should identify contributors, though it may emerge as information becomes available that the involvement of others would be useful – in particular, information of relevance to the review may become available through criminal proceedings.

Each relevant service should designate an appropriate professional to be the review panel member. Each Safeguarding Adults Review needs consistent input and engagement from the agencies involved in order to ensure and efficient and high-quality end product. This needs to be considered when selecting the panel member. The Safeguarding Adults Review subgroup and Lead Reviewer should make recommendations as to who should form the review panel. The review panel should consist of representatives from the Buckinghamshire Council Adult Social Care, Health and the police and other representatives as appropriate to the individual case. They should also start to look at the Terms of Reference for the panel which will help to inform who should be part of the panel. There should be at least three people on the panel excluding the Chair.

As part of the process of information gathering each agency may want to undertake a separate management review of its involvement with the adult. This should begin as soon as a decision is taken to proceed with a review, and sooner if a case gives rise to concerns within the individual organisation.

Where a court of protection contributes to the review, prior agreement of the court should be sought so that those bound by a duty of confidentiality under court rules are able to contribute.

12. Process for Conducting a Safeguarding Adults Review

The following process is proposed following the decision to commission a review being ratified by the Safeguarding Adults Board Chair:

12.1 Set up meeting

A panel should be convened. The first task of the panel is to agree:

• terms of reference already outlined by Safeguarding Adults Review subgroup;
• what information is required from each agency or person, stating whether this is through investigation or collected in other ways;
• how and whether the vulnerable adult, family, carer or significant others are to contribute;
• Chair of Panel to write to Chief Executive of each organisation involved;
• support and other resources needed;
• timescales for reports to the chair of the panel and completion of the review;
• dates, times and places of meetings;
• any legal advice required, in particular:
  • data protection;
  • Freedom of Information Act;
  • Human Rights Act;
  • Mental Capacity Act.

12.2 Subsequent meetings

A number of subsequent and sequential meetings will take place dependent on the complexity and nature of the review. Where possible the dates for these meetings should be set in advance. Panel members should make every effort to prioritise these meetings to ensure consistent engagement and the production of a quality end product.

12.3 Information gathering

This may include:

• production of chronologies;
• individual management reviews (IMRs) if used;
• interviews with staff and family;
• practitioner events.

12.4 Production of overview report

This should include all action plans from individual management reports plus any further actions from the lead reviewer. Action plans should be explicit about:

• actions, expected outcomes and who is responsible;
• timescales for completion.

12.5 Sign off by Review Panel

Review of the findings against the agreed terms of reference or requirements. The Panel chair should ask the review panel to sign off the Safeguarding Adults Review.

Each completed SAR report will come with a set of recommendations as proposed by the author of the report. It is the role and responsibility of the Panel to ensure that these recommendations are converted into an Action Plan that supports the delivery and ensures the impact of the recommendations.

Every completed SAR report and Action Plan, once agreed and signed off by the Panel will need to be viewed and agreed by the Safeguarding Adult Subgroup. The subgroup will then formally sign off both documents before sending them to the Safeguarding Adults Board for approval.

12.6 Presentation to Safeguarding Adults Board

The Safeguarding Adults Board should agree what action is to be taken from the findings and:

• make sure that the overview report includes an executive summary and decide if both are going to be made public;
• agree an action plan from the recommendations in the overview report, to be included in the board’s overall work plan;
• include the findings from any Safeguarding Adults Review in its annual report together with what actions it has taken/intends to take in relation to those findings;
• programme for lessons learnt.

Following presentation of SAR to Board and approval of report by the Board the SAR subgroup will:

• develop a Media statement;
• notify agencies involved in process of intent to publish with a copy of media statement and all documents (secure/draft);
• notify families of intent to publish;
• document published on website.

Some SAR’s will require a more formal publication process and the level of publication process required will be confirmed by SAR subgroup.