1. WHAT CAN WE LEARN FROM COMPLETED SARS?
FINDINGS FROM TWO THEMATIC REVIEWS UNDERTAKEN BY MICHAEL PRESTON-SHOOT

2. Care Act 2014: statutory duty to review serious cases
An SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if…

3. SAR Statutory Duty
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
(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).

4. SAR Statutory Duty or the adult is still alive, and
the SAB knows or suspects that the adult has experienced serious abuse or neglect.
An SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

5. Focus of Studies What learning themes emerge?
How does the learning help us understand what goes wrong?
What changes are recommended in order to prevent recurrence?
Sample 38 SARS
12 organisational abuse
13 self neglect
7 combined involving neglect with self neglect

6. 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 / meaning
Failure to think family
Concerns about service quality

7. Direct Practice With the Adult
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
Unclear focus on individuals wishes, needs and desired outcomes.
Focus on autonomy excludes consideration of risk to others and duty of care
MSP
Lack of curiosity about meaning of behaviour and key features in a biography
Understanding and History

8. 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

9. Organisational Factors
Missing or unclear policies; lack of attention to roll out
Safeguarding knowledge and confidence
Failure to ensure staff competence for work required
Insufficient attention to legal powers and duties

10. Interagency Cooperation
Learning about working together
Silo working
Failures of communication and information sharing
Lack of leadership and coordination
Absence of challenge to poor service standards
Absence of legal literacy
Collective omission of “the mundane and the obvious”

11. Interagency Cooperation
Absence or non-use of multi-agency forum
Absence of Escalation
Inadequate recognition, referral and response to safeguarding

12. Conclusions Unique and complex pattern of shortcomings
Learning rarely confined to poor practice
Weaknesses in all layers of the system
Taken together they add up to a ‘fault line’

13. Next Steps Locally Following related safeguarding adults forum we will
Disseminate information via different methods including
Chair of the Board newsletters
Podcasts
Posters
Forum engagement

14. Next Steps
TSAB will review completed action plans within agreed timescales to check on how well SAR recommendations have been implemented - ‘so what’s changed in reality’
TSAB is reviewing its governance systems for the commissioning, management and reviewing of safeguarding adult reviews.

15. Next Steps
We are working with regional ADASS to produce consistent guidance on common themes such as
Threshold guidance
Risk Assessment
Self neglect

16. Safeguarding Contact Points
To raise an adult abuse safeguarding referral please contact or
To make a safeguarding adult review referral contact or mark subject as SAR referral
Julie Foster – Independent Chair, Torbay Safeguarding Adults Board. Contact via or
Jon Anthony – Torbay Operational Lead