The overall purpose of a Safeguarding Adult Review (SAR) is to promote learning and improve practice. The objectives include:
- To learn about how to improve how professionals and their agencies work together
- To review how effective local multi-agency safeguarding procedures are
- To share guidance, best practice approaches and celebrate good practice
Below are details of the Safeguarding Adult Reviews commissioned by SSASPB.
Clive Discretionary SAR (2024)
Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a discretionary Safeguarding Adults Review under section 44.4 of the Care Act 2014.
Clive had a learning disability, epilepsy, and complex mental health needs. This discretionary SAR relates to historical incidents of abuse, which were considered in the context of current practice and process under Care Act 2014 safeguarding and commissioning arrangements.
Concerns related to sexual abuse by a person in a position of trust (PiPoT), a lack of trauma informed practice and support to Clive and how agencies respond to and work with families who raise issues of care quality.
Gillian SAR (2023)
Gillian was in her late 60s and restricted to her bed in a supported housing location. Concerns related to self-neglect, refusal of services and consideration or use of Mental Capacity Act (2005) legislation and to what extent this impacted on Gillians outcome.
The reviewer introduces the case and themes below.
Frank and Elsie (2023)
This SAR focuses on the response to risk presented by sexual behaviours in care/nursing settings. The case involved two residents who both lacked capacity. SSASPB partners have produced a podcast to introduce the themes of the case.
Anne (2022)
Anne, a divorced white British woman in her late eighties who lived alone in social housing. It seems that Anne had enjoyed good health and independence until a fairly rapid decline in her health and ability to take care of herself. Anne experienced falls at home during the summer, resulting in hospital visits via ambulance. Following a second admission to the Accident and Emergency department, she was not admitted and returned to her home address. The domiciliary care package was not reinstated as it was the belief of the provider that Anne would be admitted to hospital. Anne was discovered deceased at her home address following an alert made by friends who had travelled to deliver a birthday card to her several days after her return home.
Andrew (2022)
A short audio clip giving an overview of the Andrew SAR and the lessons to learn from the review.
Heather (2022)
John (2018)
Themes – inter-agency communication, record keeping, lead practitioner, timeliness of progress of enquiries
John was in his 60's and had a learning disability and a long diagnosed mental health condition, together with other medical conditions which included difficulties with swallowing food. He was placed by one local authority into a care home situated in a neighbouring local authority where he lived for many years.
John’s health deteriorated, and he was observed to start unusual eating habits, including taking and eating frozen food during the night. At a multi-disciplinary team meeting held in March 2016 it was agreed that he required a ‘waking’ night staff rather than the current ‘sleep in’ arrangements to monitor his nocturnal activity due to the heightened concerns of him taking food. Before the staffing arrangements were put into place John took food which was not fork mashable from the kitchen during the night and was found deceased the following morning by care home staff. A post mortem examination recorded the cause of death as ‘choking’ with a secondary cause of cerebral vascular disease.
Areas for improvement:
- There was poor verbal and written communication which needs addressing for person centred care to be effective. Better record keeping would have improved everyone’s knowledge about John’s care and support needs. The Care Home staff were in the best position to monitor John’s well-being and information sharing with others engaged in meeting his needs could have been improved.
- There was a lack of a holistic and coordinated approach to the complex needs of adults with care and support needs. This doesn’t necessarily need to be the NHS or Local Authority, the care home staff could have co-ordinated activity.
- There is a potential disconnect between the information from quality inspections of care homes, individual safeguarding enquiries and wellbeing assessments meaning that all information needed to address the circumstances of adults with care and support needs is not available and not addressed.
- The confusion about roles and responsibilities undermined care planning and safeguarding planning. Where there are cross boundary matters it would be beneficial to clarify roles and responsibilities early on in any enquiry.
- The Lack of clarity regarding who should carry out a mental capacity assessment with John regarding food choices and actions left him at risk.
- Full report - John
David (2017)
Themes - Self-neglect, alcohol misuse, challenges to engagement
David had lived with his mother, but had to move from the family home after her under the ‘under-occupancy’ ruling. The loss of his mother had a significant emotional impact upon David and he became very lonely. David appears to have been unable or unwilling to care for himself. He had a lengthy history of excessive alcohol use. Several agencies were involved in supporting him at home; his personal hygiene was extremely poor and his home was unclean most of the time. There were issues of mobility reported however when David was seen in Police custody by the mental health team there was no record (or recollection by staff) that he was unable to move freely. He had several mental health assessments which didn’t result in the offer of ongoing treatment.
Agencies were involved in trying to support him to reduce and eventually stop his alcohol use however he declined offers of inpatient detox. Adult Social Care maintained appointeeship for David in an attempt to reduce his access to alcohol, they also arranged for him to receive care at home. This was initially two calls per day, but this changed to one longer call to support him more effectively with his personal care. The Ambulance Service was repeatedly called by David, sometimes daily, and regular, inappropriate and unnecessary calls made to Police. It is believed that this was mainly because of boredom and loneliness. David’s presentation caused unpopularity in his community as he was often soiled and unclean.
At the inquest the Coroner recorded that death was because of bronchopneumonia, chronic obstructive pulmonary disease, skin ulceration and chronic alcoholism. Whilst there were no concerns about provision of care offered, SSASPB decided to conduct a multi-agency learning review to better understand the links between substance misuse, mental ill-health and self-neglect as many professionals were left wondering what they could have done to improve David’s willingness to engage with them. The review highlighted areas of good practice and those where improvements could be made.
Lessons learned:
Areas of good practice:
- GP was excellent at sharing their concerns with other agencies including ASC and WMAS
- Housing allowed David to remain in the home he shared with his mother over and above any usual timescale as the house met under-occupancy scheme.
- David’s situation was referred to the Vulnerability Hubs for information sharing
- Excellent support provided over the phone at 2am by the Mental Health Access Team.
Areas for improvement:
- There was an over reliance on alcohol misuse to explain presentation
- There is a service gap for multi-occupancy housing provision for U55s - loneliness
- Need for creativity for people with extremely poor self-hygiene to make sure that they can access support e.g. church, self-help groups, voluntary services.
- Full documentation on case files is essential, allows others to really understand why decisions were made and trends in well-being.
Learning from reviews to improve practice: Short notice closure of the Nursing section of a Nursing and Care Home
In August 2017 there was considerable and serious professional concern about the nursing unit of a Care Home in Stoke-on-Trent. This led to the regulator, the Care Quality Commission (CQC,) arranging an urgent inspection which in turn led them to requiring the immediate closure of the nursing unit of the home. A combination of health and social care agencies were involved in the practical arrangements to achieve this. They worked alongside the owners and staff of the home. Both nursing and social care staff were allocated to arrange urgent assessments of all residents while other staff were involved with informing relatives and staff at the home. The third element was identifying alternative and available placements that would meet the needs of each individual resident.
The task was completed within less than a week and overall the transfer and outcomes achieved were considered to be a success. However, there was universal concern from those involved that although the outcomes were largely positive the process of arriving there was confusing and at times chaotic. There was a view that, despite substantial goodwill and energy from staff from all agencies, the result was in part fortunate and there was little confidence that in a similar future event such a positive outcome could be guaranteed. The Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board decided to commission an independently led Multi-Agency Learning Review from which to identify lessons to be learned and to improve future processes and practice.
Areas of good practice:
- Despite the at times chaotic response to the fast-paced situation there was excellent collaborative working by all involved agencies, including working with partners across geographical boundaries. There was a tangible desire and will to make things happen as quickly and as effectively as possible in a very challenging situation
- The willingness of the Care Home owners to participate in the Multi-Agency Learning Review
- Acknowledgement by all that there are areas for improvement and a willingness to work together to achieve this for the benefit of future similar situations Areas for improvement:
- The SSASPB partners are to consider how WMAS data about frequency of incidents at a care or a nursing home could be used to prevent incidents of abuse and neglect
- To seek assurance that Commissioners of care have appropriate mechanisms to share both hard and soft information about nursing and care homes that is informed by, and in turn informs, front line staff
- The local partnership of the Council, NHS agencies and the CQC should have an agreed written process to support the short-term closure of homes and that staff are aware of this. The policies should reflect national good practice.
- The guidance is to include how the Police may capture evidence with which to consider any criminal justice process.
- The local partnership should consider testing the procedures, for example by using simulated exercises, to further identify improvements.
Emergency closure of a nursing unit (2017)
National learning from Safeguarding Adult Reviews in other areas
National learning: We also reflect on national learning from SARs and other review processes available nationally. A national database of SARs published from 1st April 2019 is available for SAB, professionals and the public to review findings and recommendations from a national perspective. The search functions mean that cases can be narrowed down to types and locations of abuse, types of care and support need and safeguarding themes.
Social Care in Excellence (SCIE) have also published a useful video 'Have we learned from Steven Hoskin’s murder? (2020)' as a ten year reflection following his murder by people who targeted him because of his learning disabilities.
The Care and Health Improvement Programme (CHIP) has completed two national analysis reports on SAR in partnership with the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS) in England. The purpose of the analysis was to identify priorities for sector-led improvement as a result of learning from SARs completed between 2019 and 2023, a period of time that included the COVID-19 pandemic. The analysis builds on the findings of the first national analysis, published in 2020, which considered learning from SARs completed between 2017 and 2019.
Links to the full reports and executive summaries available on the LGA website are below, as well as to a range of briefings in relation to the SAR National Analysis for a range of audiences including SAB Chairs and Managers, senior managers and elected members, practitioners, as well as for individuals and families.
Ø Analysis of Safeguarding Adults Reviews (SARs) April 2017 – March 2019
Ø Analysis of Safeguarding Adult Reviews: April 2019 – March 2023
Ø Second national analysis of Safeguarding Adult Reviews: April 2019 – March 2023 (executive summary)
Ø Briefing for SAB chairs and business managers: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for senior leaders and SAB members: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for individuals and their families: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for elected members: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for authors of Safeguarding Adult Reviews: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for practitioners: Second national analysis of Safeguarding Adult Reviews
Ø Briefing for individuals and their families – Analysis of Safeguarding Adults Reviews
Ø Briefing for practitioners – Analysis of Safeguarding Adults Reviews
Ø Briefing for Safeguarding Adults Reviews authors – Analysis of Safeguarding Adults Reviews
Ø Briefing for senior leaders – Analysis of Safeguarding Adults Reviews
Ø Briefing for Safeguarding Adult Board chairs and business managers – Analysis of Safeguarding Adults Reviews
Ø Briefing for elected members – Analysis of Safeguarding Adults Reviews