what can we learn from completed sars? findings …€¦ · findings from two thematic reviews...
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WHAT CAN WE LEARN FROM
COMPLETED SARS?
FINDINGS FROM TWO THEMATIC
REVIEWS
Michael Preston-Shoot (Researcher with Suzy Braye)
ESRC Seminar – University of Bedfordshire
16th February 2018
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Care Act 2014: statutory duty to review
serious cases
• SABs must arrange a Safeguarding Adult Review (SAR)
when:
• An adult dies as a result of abuse or neglect, or experiences
serious abuse or neglect and
• There is concern about how agencies worked together to safeguard
them
• The purpose:
• To identify lessons to be learnt from the case and apply those
lessons to future cases
• To improve how agencies work, singly and together, to safeguard
adults
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The focus of the studies
Key questions
• What learning themes emerge from SARs conducted in London and SW?
• How do the learning themes help us understand what goes wrong?
• What changes are recommended in order to prevent recurrence?
The approach
• Sample
• 27 SARs (London), 11 (SW)
• Not all SABs released full
reports
• Two forms of analysis
• SAR characteristics: type of
case, type of review, type of
recommendations
• SAR content: factors
contributing to the case
outcome
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The cases
• Demographics
• All age groups represented, London emphasis on people 60+
• Three-quarters involved individuals who had died
• Almost half London sample related to group living situations
• More cases involved men
• Ethnicity usually unspecified
• Type of abuse
• Organisational abuse (9 – London) (3 – SW)
• Self-neglect (7) & (6) with several more since the studies
• Combined(5) & (2) often involving neglect with self-neglect
• Almost all were statutory reviews
• Did not routinely indicate source of referral
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SAR characteristics: methodology
Documentary analysis:
chronologies & IMRs (9) (2)
Hybrid/ custom-built approaches
(12) (5)
“Learning Together” (6)
(1)
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Review period • 2 weeks – several years
• Occasionally not stated
Independence • Occasionally questionable
Family involvement • Just over half of the reviews
• Offered and declined in most other cases
Individual’s involvement • Where individual alive, unusual for reviews to
indicate whether their involvement considered
Length of review process • Not always clearly stated
• Only 2 within 6 months
• Delays: parallel processes, poor quality
information, lack of engagement
Length of report • 2-98 pages
• Median 33 (London) 24 (SW)
• Executive summaries 2-18 pages
Recommendations • 3-39 (London) 3-15 (SW)
• Increasingly to the Board
• Recommendations to national bodies rare
Publication • 8 (London) 7 (SW) published
• 4 (London) 3 (SW) summary/briefing published
• Inconsistent mention in annual reports
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SAR content: whole system
understanding
Legal and policy context
Interagency governance
Interagency features
Organisational features
Direct practice
The adult
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Direct practice with the adult
Learning about
practice
Mental capacity
Risk assessment
Lack of persistence
in engagement
Refusal taken at
face value: ‘lifestyle choice’
MSP: missing or
over-prioritised Absence of
understanding about history and meaning
Failure to ‘think family’
Concerns about
service quality
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• Assessments absent or inadequate
• Failure to recognise and act on persistent and escalating risks
Risk
• Assessments missing, poorly performed or not reviewed
• Absence of detail about best interest decision-making
Mental capacity
• Insufficient contact with the individual
• Unclear focus on individual’s wishes, needs and desired outcomes
• Focus on autonomy excludes consideration of risks to others and duty of care
MSP
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Absence of attention to complex family dynamics; failure to involve carers
Lack of curiosity about meaning of behaviour & key features in a biography
Lack of time & agency encouragement of relationship & trust building; absence of continuity
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Organisational factors
Learning about
organisations
Absence of supervision
and managerial oversight
Absence of escalation
Workflow practices constrain
involvement
Records unclear,
incomplete or missing
Resource challenges:
time, staffing, placements
Agency culture
QA and contract
monitoring
Failure to track
patterns and concerns
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Missing or unclear policies; lack of attention to roll-out
Insufficient attention to legal powers and duties
Safeguarding knowledge and confidence
Focus on case management and not reflective practice
Failure to ensure staff competence for work required
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Interagency cooperation
Learning about
working together
Silo working: uncoordinated parallel lines
Failures of communication and information-
sharing
Lack of leadership and coordination
Absence of challenge to poor service standards Absence of
safeguarding literacy
Absence of legal literacy
Collective omission of
‘the mundane and the obvious’
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Absence or non-use of multiagency forum
Use of thresholds and eligibility criteria to gate-keep
Inadequate recognition, referral and response to safeguarding
Absence of escalation
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SAB governance
Learning about
SAB role
Poor agency participation;
failure to provide
information
Debated panel membership
Value of using research to
underpin analysis and
learning
Protocols on parallel
processes
Action planning for
implementation of learning
Family involvement
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Recommendations
Legal and policy context
SAB governance
Interagency collaboration
Organisations
Direct practice
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Direct practice
Person-centred, relationship-
based practice
Assessment & review of risk and capacity
Family involvement
Availability of specialist
adviceLegal literacy
Balancing autonomy with a duty of care
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Organisational environment
Development, dissemination &
review of guidance
Clarifying management
responsibilities
Staffing, supervision, support & training
RecordingCommissioning
& contract monitoring
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Inter-organisational environment
Guidance on balancing
autonomy with a duty of care
Information-sharing &
communication
Management of complex cases
Hospital admission and
discharge procedures
Clarifying roles and
responsibilities
Senior management
oversight
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SAB governance
Audit & quality assurance of what
good looks like
Training for IMR writers & case review group
members
Review of management of
SARs
Workplace as well as workforce development
Continual review of outcome of
recommendations
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Conclusions
• Unique and complex pattern of shortcomings
• Learning rarely confined to ‘poor practice’
• Weaknesses in all layers of the system
• Each alone would not determine the outcome
• Taken together they add up to a ‘fault line’
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Recommendations to London SAB and SW SABs
Safeguarding practice
• Support SABs to
implement SAR findings
• SABs to review
safeguarding policies and
procedures in the light of
these findings
• SABs to consider further
work to track impact and
outcomes of SARs
conducted
SARs
• Expand quality markers and assurance in LSAB SAR policies
• Facilitate discussion and development of guidance for SABs on• Commissioning SARs,
methodologies, interface with parallel processes & other reviews
• Monitoring of SAR referrals and outcomes cf. patterns of abuse
• Consider further work on• Thresholds for SAR
commissioning
• Advantages/disadvantages of methodologies
Dissemination to DH and national bodies representing SAB partners
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Further details
Reports
• Braye, S. and Preston-Shoot, M. (2017) Learning from SARs: A Report for the London
Safeguarding Adults Board. London: ADASS.
• Preston-Shoot, M. (2017) What Differences does Legislation Make? Adult safeguarding
through the Lens of Serious Case Reviews and Safeguarding Adult Reviews. Bristol: SW
ADASS.
Articles
• Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Serious case review findings on the
challenges of self-neglect: indicators for good practice’, Journal of Adult Protection (17, 2,
75-87).
• Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Learning lessons about self-neglect? An
analysis of serious case reviews’, Journal of Adult Protection, 17, 1, 3-18.
• Preston-Shoot, M. (2016) ‘Towards explanations for the findings of serious case reviews:
understanding what happens in self-neglect work,’ Journal of Adult Protection, 18(3), 131-
148.
• Preston-Shoot, M. (2017) ‘On self-neglect and safeguarding adult reviews: diminishing
returns or adding value?’ Journal of Adult Protection, 19, 2, 53-66.
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Key contacts
Please contact us if you have any queries:
Professor Michael Preston-Shoot, [email protected]
Professor Suzy Braye, [email protected]