Safeguarding Adult Reviews
The Care Act 2014 introduced SARs, which were previously known as Serious Case Reviews, and carrying out these reviews is a statutory requirement for Safeguarding Adult Boards.
A Safeguarding Adult Review is a multi-agency process that considers whether or not serious harm experienced by an adult, or group of adults, at risk of abuse or neglect could have been predicted or prevented.
The overall purpose of a Safeguarding Adult Review is to promote learning and improve practice, not to re-investigate or to apportion blame.
Buckinghamshire Serious Case Reviews
Buckinghamshire Safeguarding Adults Board (BSAB) commissioned a Safeguarding Adult Review (SAR) after the death of Adult FF.
A statement from BSAB Independent Chair, Sir Francis J S Habgood;
Mr FF was an elderly Afro-Caribbean gentleman who lived alone at his home in High Wycombe, Buckinghamshire. Mr FF died at home in mid-November 2019, aged 94 years. At the time of his death, Mr FF was living in unsanitary, rat-infested conditions with evidence of self-neglect. Several agencies were involved with Mr FF. However, Mr FF did not always accept the services offered and he did not fully engage with agencies. Given the circumstances leading up to Mr FF’s death, the BSAB commissioned an Independent Reviewer to undertake a SAR.
The organisations that had contact with Mr FF in the months leading up to his death were asked to provide chronologies and to complete management reviews setting out their involvement. A practitioners’ event was held to explore good practice, missed opportunities and learning. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case.
This was a complex case and Mr FF was extremely vulnerable and at risk. There is evidence of positive multi-agency working and of information sharing in this case but there were significant delays in responses. The local safeguarding system did not work effectively enough to ensure that timely and decisive action was taken to safeguard Mr FF.
The review helped to inform on-going work of the Board to develop guidance and procedures for managing cases of self-neglect where the individual does not want to engage with agencies. The report contains 5 recommendations which were considered by the BSAB in September 2021, these were accepted, and an action plan has been developed to ensure that the improvements are implemented.
In line with good practice, the Safeguarding Adults Review Sub-Group will monitor progress against a multi-agency Action Plan. This will be formally reported to the BSAB on a regular basis, and the Board will require evidence-based assurance that sustained improvements are in place.
SAR FFBuckinghamshire Safeguarding Adults Board (BSAB) commissioned a Safeguarding Adult Review (SAR) after the death of Adult CC in April 2019. The report is published below:
Mr CC was a 58-year-old man living in supported accommodation at ‘Round Coppice Farm’ provided by ‘Enriched Care’ in Buckinghamshire. He had a long history of schizophrenia and substance abuse. There was a fire in his bedroom on 10th April 2019 and CC died as a result. The cause of death has not been formally established by the Coroner at the time of publication of this report. Adult CC’s placement in his accommodation was funded by Berkshire Healthcare NHS Trust. Given the circumstances leading up to Mr CC’s death, the BSAB commissioned an Independent Reviewer to undertake a SAR.
Most of the organisations that had contact with Mr CC in the months leading up to his death were asked to provide chronologies and to complete management reviews setting out their involvement. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case. Investigations and enquiries by the police, Fire and Rescue Service and Health and Safety Executive were running at the same time as this review and so key pieces of information from them and the accommodation provider were not available to the author.
The review identified some serious concerns about the care and support offered to Mr CC, particularly in relation to the placement of him in inappropriate accommodation. The report highlights opportunities for learning and some areas of good practice. The report contains 10 recommendations which were considered by the BSAB in December 2020. Those for BSAB were accepted and an action plan has been developed to ensure that the improvements are implemented. Contact has also been made with organisations outside Buckinghamshire to ensure that their recommendations are being actioned.
At the end of 2020, a decision not to pursue a criminal case provided an opportunity to include information to from Enriched Care. This delayed publication of the report but ensured that further possible lines of enquiry could be captured.
In line with good practice, the Safeguarding Adults Review sub-group will monitor progress against a multi-agency Action Plan. This will be formally reported to the BSAB on a regular basis, and the Board will require evidence-based assurance that sustained improvements are in place.
Statement by Sir Francis Habgood QPM
Independent Chair of Buckinghamshire Safeguarding Board.
SAR CCBuckinghamshire Safeguarding Adults Board (BSAB) commissioned a Safeguarding Adults Review (SAR) in 2015. A summary of the report is published below:
There has been a considerable delay between the commissioning of the review and its publication (2015 to 2019). This was caused by a number of factors including: a parallel review by the Prison and Probation Ombudsman, published in February 2019; a Coroner’s Inquest, concluded in January 2019; and the need to examine gaps identified in the initial draft report, presented in November 2016.
Whilst I am reassured that opportunities to learn from this case have not been delayed, the timeliness of publication is too slow. Steps are in place to ensure that reports are published in a more timely way.
At the time of his death Mr L was in contact with and known to a number of local services in Buckinghamshire. Therefore given the circumstances of his death, the BSAB commissioned an Independent Reviewer to undertake the SAR. This was to uphold its commitment to an open and transparent review process which would establish whether there were lessons that needed to be learnt in order to improve practice and better support people in Buckinghamshire, particularly those with learning difficulties.
All of the organisations that had contact with Mr L in the three years leading up to his death were asked to provide chronologies and to complete management reviews setting out their involvement. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case.
The Review made 11 recommendations and the majority of these have now been implemented or, where the action is more complex, are in the process of being implemented.
In line with good practice, the Safeguarding Adults Review Sub Group will continue to monitor progress against a multi-agency Action Plan. This will be formally reported to the BSAB on a regular basis, and the Board will require evidence based assurance that sustained improvements are in place.
Francis J S Habgood
Independent Chair
Buckinghamshire Safeguarding Adults Board
SAR L Executive summary
Buckinghamshire Safeguarding Adults Board (BSAB) commissioned a Safeguarding Adults Review (SAR) in September 2018. A summary of the report is published below:
Concerns regarding the way in which disclosures made by Adult BB were dealt with by multiple agencies were raised by Buckinghamshire Healthcare NHS Trust. The referral raised concerns around the multi-agency response to repeat allegations made by Adult BB of rape by a member of staff employed at her residential/nursing home. Therefore, given the circumstances, the BSAB commissioned an Independent Reviewer to undertake a SAR. This was to uphold its commitment to an open and transparent review process which would establish whether there were lessons that needed to be learnt in order to improve practice and better support people in Buckinghamshire, particularly those had made allegations of this nature.
All of the organisations that had contact with Mrs BB in the months leading up to and after the allegations were made were asked to provide chronologies and to complete management reviews setting out their involvement. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case.
The Review identified opportunities for learning and also areas of good practice, particularly in relation to the response from Adult Social Care and Thames Valley Police when the allegations were eventually passed to them for investigation. The report identifies 9 recommendations which were considered by the BSAB in September 2019. The majority of these were accepted and an action plan is now being developed to ensure that the improvements are implemented. The recommendation to conduct an audit into further cases will not be implemented at this time, as it was felt that the learning from this case should be embedded first and then the need for a later audit could be considered in due course.
The BSAB were also reassured to hear that the on-going needs of Mrs BB are being prioritised.
In line with good practice, the Safeguarding Adults Review Sub Group will monitor progress against a multi-agency Action Plan. This will be formally reported to the BSAB on a regular basis, and the Board will require evidence based assurance that sustained improvements are in place.
Francis J S Habgood
Independent Chair
Buckinghamshire Safeguarding Adults Board
SAR BB Executive Summary
Buckinghamshire Safeguarding Adults Board (BSAB) commissioned a Safeguarding Adults Review (SAR) after the death of Adult Z in July 2018. A summary of the report is published below:
A number of teams from different agencies provided services to Mr Z in the months leading up to his death. The referral raised concerns that there were missed opportunities in engaging with him, that he received different responses from agencies and that processes were not always followed. Additionally there might have been missed opportunities in terms of his palliative care pathway. Therefore, given the circumstances, the BSAB commissioned an Independent Reviewer to undertake a SAR. This was to uphold its commitment to an open and transparent review process which would establish whether there were lessons that needed to be learnt in order to improve practice and better support people in Buckinghamshire.
All of the organisations that had contact with Mr Z in the months leading up to his death were asked to provide chronologies and to complete management reviews setting out their involvement. These formed the basis of the review and enabled a fuller understanding of the circumstances of the case.
The Review identified opportunities for learning in relation to communicating with individuals who suffer sensory impairment, conducting needs and risk assessments when individuals decline services and the process for escalation when a person’s health deteriorates. The report did also commend the efforts of one individual who showed great care and tenacity to support Mr Z. The report identifies 7 recommendations which were considered by the BSAB in September 2019. These were accepted and an action plan is now being developed to ensure that the improvements are implemented.
In line with good practice, the Safeguarding Adults Review Sub Group will monitor progress against a multi-agency Action Plan. This will be formally reported to the BSAB on a regular basis, and the Board will require evidence based assurance that sustained improvements are in place.
Francis J S Habgood
Independent Chair
Buckinghamshire Safeguarding Adults Board
SAR Z Executive Summary
SAR Z Overview Report
SAR Referral Requests are submitted to the SAR Sub Group and considered against the SAR criteria. BSAB partner agencies should ensure that Serious Incidents which may meet the criteria for a SAR are also brought to the attention of the BSAB SAR Sub Group using this form. For cases that do not meet the criteria for a SAR, the Sub Group will consider where another form of partnership or learning review may be appropriate to ensure lessons are learned.
Where partners feel a serious incident does not meet the definition for a SAR, but cannot be dealt with internally by the referring agency alone, then the Sub Group can consider making a recommendation on whether there should be a wider review involving more than one agency. This form should also be used for referring such cases.
Anyone wishing to refer a case to the SAR Sub Group should discuss the case, and their reasons for referring it, with their agency’s Designated Safeguarding Lead/Officer before making the referral. They should then notify the BSAB as soon as possible.
Please use the SAR Referral Form and send the completed form to bsab@Buckinghamshire.gov.uk
For more information on Safeguarding Adults Reviews, please see the SAR Information Leaflet
Safeguarding alerts should be sent to Safeguardingadults@Buckinghamshire.gov.uk
The Local Government Association (LGA) have produced a series of 7 minute briefings for different audiences regarding the findings of the national SAR analysis: