Learning Lessons from Safeguarding Adult Reviews (SARs)

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Presentation transcript:

Learning Lessons from Safeguarding Adult Reviews (SARs) MQNF 1st March 2017 Helen Jones  Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board Manager helen.jones4@staffordshire.gov.uk Steve Dale Adult Safeguarding Team Leader, Staffordshire County Council stephen.dale@staffordshire.gov.uk Liz Osburn Training Officer, Adult Safeguarding liz.osburn@staffordshire.gov.uk

This Briefing will Consider: When the Safeguarding Adults Board will undertake a SAR and its purpose Failings and why things go wrong The process for referral for SAR Opportunity to question at end What we won’t be talking about -procedure

In April 2015 the requirement to undertake SARs became statutory through the Care Act 2014, Section 44 Safeguarding Adult Review if- a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult and b) either of the following conditions are met

a) The adult has died, and b) The SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died) a) The adult is still alive, and b) The SAB knows or suspects that the adult has experienced serious abuse or neglect

“The overriding reasons for holding a review … “The overriding reasons for holding a review ….to learn from past experience, improve future practice and multi‐agency working. It is not the role of Safeguarding Adult Reviews to apportion blame ‐ that is for the courts or other arenas.’’ Inform of other processes: DHR Inquests Criminal investigation Disciplinary HSE Regulatory Processes SI Professional Body –NMC,GMC, HCPC Etc. Flexibility within the legislation to be proportionate with the SAR – depth, intensity , time, cost, ‘Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services’ (March 2013)

The Purpose of the SAR Establish the facts Establish whether there are lessons to be learnt Review the effectiveness of procedures Inform and improve local inter-agency practice and commissioning arrangements Improve practice Highlight good practice Provide an overview report After this – production of development plan

Safeguarding Adult Reviews in Staffordshire Case examples

23 year old woman ate herself to death due to rare disorder Woman eats herself to death after care home removes fridge locks 23 year old woman ate herself to death due to rare disorder 23 year old died from heart failure after putting on 7st in nine months. She had been living in care home in Staffordshire Kirsty Derry – see case synopsis in file Others ongoing …ECM A 23-year-old woman from the United Kingdom……

Themes identified…. 3 areas

Knowledge Understanding of service user needs Roles and responsibilities –yours and others’ Legislation –duties and powers Domestic Abuse Procedures Understanding of thresholds Specialist needs (KCD) What you should be doing/What can you expect from others –do you know how to refer to others What should the LA be doing ( duties under Care Act) , MCA and MHA

Behaviours Compliance Lack of curiosity Insular approach Poor communication Poor risk assessment Lack of supervision Lack of challenge Lack of personalisation

Systems Institutionalised practice Number of structures Complex structures Learning/development opportunities Escalation processes

Notable in Staffordshire and Stoke Reviews…… Importance of whole family assessment Intergenerational Abuse Issues identified around Inter departmental communication Food/eating and associated risks a common theme Lack of availability of data in relation to domestic abuse and those with care and support needs Total SAR/DHR ( ? Over what period of time) ECM KD –learning review MCM HT – DH learning review SJE The need for professional curiosity and move away from ‘tick box’ culture Lack of application of the Mental Capacity Act

The Referral Process

Your Questions