Research: Thresholds inconsistencies in adult serious case reviews

Ann McDonald explores an analysis of 22 adult serious case reviews which suggests the lack of clarity in threshold levels is holding back learning for social workers


KEY WORDS: serious case reviews adult safeguarding adult protection enquiries adult abuse policy

AUTHORS: Jill Manthorpe and Stephen Martineau

Title: Serious Case Reviews in Adult Safeguarding in England: An analysis of a sample of reports

Published by: British Journal of Social Work (2010) 1-18.

Aim: This article reports an analysis of 22 serious case reviews in respect of vulnerable adults, conducted by English adult protection or safeguarding boards when death or harm has occurred. The article presents a reflection on the purpose, process and usefulness of SCRs as one way of learning retrospectively from serious incidents. The context is the current review of adult safeguarding policy in England which has received calls for a more consistent approach to SCRs and for lessons learned to be analysed and more widely circulated.

Methodology: The article is based on an independent report by the authors commissioned by the Department of Health. This article is a documentary analysis of the original set of 15 SCRs, augmented by seven further summary reports.

Conclusion: The current lack of clarity in terms of the threshold for a review and the conduct of reviews means it is difficult to consider system failings and to generalise learning for agencies and practitioners.

Unlike their equivalents in chidren’s services, serious case reviews in adult safeguarding are not public documents. So this analysis of 22 SCRs ought to inform policymakers and practitioners about the differences in how reports are conducted and used, and how the process could be improved.

The reports were analysed in terms of rationale, threshold for instigating an SCR, form of abuse, review personnel, methodology, cost, timescale, recommendations and lessons learned, and action plans. A telephone survey of statutory social care agencies from the research study on which the article is based (Manthorpe and Martineau, 2009) is briefly referred. This showed that, commonly, there was no protocol for reviews in place, ready to be invoked should the need arise. There were also few examples of SCRs conducted into incidents occurring in the NHS or criminal justice systems. It is hoped that the ­establishment of the Care Quality Commission as a combined health and social care ­regulator will accelerate greater compatibility of systems.

Though the study indicates that the principle of “learning lessons” is well understood as the rationale for SCRs and supported as such, there was considerable variation on the issue of thresholds that make any particular case or incident deserving of a review. A lack of co-operation from other agencies is put forward as one of the reasons for delays in progressing some SCRs (as in children’s SCRs).

The absence of a national database to bring together recommendations from SCR reports is also lamented; a major issue arising from this research is the inaccessibility of reports.

Limited resources for staffing adult safeguarding services in some areas is proposed as an explanation for records being lost; another explanation put forward is that there has been limited attention to data collection and recording more generally in adult safeguarding.

As the authors correctly state, despite the interest in local adult SCRs among the social work and adult safeguarding community, there has been little exploration of their content, process, analysis or recommendations. This article is therefore a welcome addition to the knowledge base.

Its focus is on the rationale and process of SCRs. As such its major contribution is to the policy debate around the review of No Secrets (Department of Health, 2009). SCRs themselves are reviews of systems, and especially of joint working, rather than investigations or inquiries into the “narratives” of particular incidents.

The 22 cases are not described or analysed in detail or placed in the context of previous research about the prevalence or incidence of abuse. The issues identified in the reports are presented in tabular form; chief among these are deficits in inter-agency communication and the need for further training.

Remarkably, five reports comment on a lack of clarity as to the lead agency – a role clearly assigned to the local authority under No Secrets.

The full report of the research from which this article is derived (Manthorpe and Martineau, 2009) repays further reading. That report includes interviews with individuals involved in the commissioning or execution of SCRs, giving qualitative data on their experience of undertaking reviews. There is also a useful comparison with SCRs in child protection. Convincing evidence is provided to support national guidance on SCRs, including their relationship to other types of review; support for a national collation of SCRs; consideration of a duty to co-operate between agencies; a rationale for the appointment of independent chairs; and agreed review periods for action plans. The full report thus addresses practitioner concerns more critically than the due process model which is presented in the article.

What is missing from the discussion is a consideration of the benefits of including practitioners, service users and families in the review process, to construct as well as to be beneficiaries of lessons to be learned from such reviews. The importance of ­disseminating learning more widely, ­including dissemination to the care home sector (the location of concern in 13 of the 22 index cases), could be the focus of further research into methods for doing this most effectively, and providing training for practitioners. Caution has, however, been raised in relation to children’s services that the escalating costs of SCRs may divert resources away from developing practice on the ground (Brandon and colleagues, 2008).

Practice implications

For policymakers

● Consideration should be given standardising the approach to SCRs in adult safeguarding.

● Greater clarity is required in setting thresholds for SCRs.

● Lessons to be learned from SCRs should be analysed and more widely circulated.

● Guidance is required in relation to inter-agency co-operation, information-sharing and data protection.

For managers

● Investigation of “near misses” that occur below the threshold will inform good practice generally.

● Communication between agencies is required to identify failing services.

● Adequate resources are needed to monitor and disseminate findings from adult safeguarding referrals.

For practitioners

● Greater transparency of practice is necessary to inform follow-up training.

● Practitioner and service user involvement in the SCR process is in need of further consideration.

● The incidence of neglect in this sample of reports raises questions about current practice in residential establishments.

Further reading

● Association of Directors of Adult Social Services (2006), Vulnerable Adult Serious Case Review Guidance: Developing a Local Protocol

● Brandon M, Bailey S, Belderson P, Gardner R, Sidebotham P, Dodsworth,J, Warren C, and Black J (2008), Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005-2007, Research Report RR 129, Department for Children, Schools and Families

● Department of Health (2009), Report on the Consultation: The Review of No Secrets Guidance

● Mandelstam M (2009), Safeguarding Vulnerable Adults and the Law, Jessica Kingsley Publishers

● Galpin D (2010), “Policy and the protection of older people from abuse”, Journal of Social Welfare and Family Law 32:3, 247-255.

Ann McDonald is head of school of social work at University of East Anglia

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