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How research into adult safeguarding investigations is informing social work practice

The Winterbourne View case demonstrates the importance of talking directly to people affected by abuse and their families, writes Jill Manthorpe, professor of social work and director of the Social Care Workforce Research Unit at King’s College London

The Winterbourne View serious case review is a powerful read
The Winterbourne View serious case review is a powerful read

Latest research findings

There is remarkably little controversy over the Care and Support White Paper (DH, 2012) – once debates over funding had been kicked into the long grass. After all, who could oppose the idea of better information, clearer entitlements, and more support for carers? One further area where some changes are proposed is adult safeguarding. Here we look at the specific proposals for serious case reviews (SCRs).

The draft Care and Support Bill proposes that part of the role of safeguarding adults boards (SABs) will be to undertake reviews of cases where there is suspicion that an adult is experiencing abuse or neglect, and where a person dies or there is reasonable concern over how an agency has acted (this could presumably include injury or a ‘near miss’). Clause 36(2) places a duty on SAB members to co-operate and contribute to carry out the review. Social workers will therefore be able to propose that a SCR is warranted or not, will have to take part in the processes, and could be responsible for implementing recommendations.

The publication of the SCR into Winterbourne View Private Hospital (Flynn, 2012) shows the power and influence of SCRs. But the Winterbourne SCR is an exception (Manthorpe and Martineau, 2011), being so high-profile. Other SCRs are more local in focus and may not have an independent chair or be able to command major resources (Manthorpe and Martineau, 2012).

Less is known about the reports that social workers and others may write prior to SCRs and which the SCR panel will consider. Indeed, such documents may be used as an alternative to a SCR, internal review, or inquiry. Sometimes known as internal management reviews (IMRs), the ‘detective work’ of compiling these is familiar to social workers in other contexts who have to respond to complaints or concerns.

Nonetheless, the Winterbourne View SCR is a powerful read and a research document in its own right. Flynn found that South Gloucestershire Council adult safeguarding service had received 40 safeguarding alerts about patients of Winterbourne View Hospital. These concerned patients who had been ‘imported’ from other localities.

The safeguarding service’s expectation that hospital staff would honestly report the circumstances concerning all allegations of abuses and crimes was misplaced and Flynn perceives staff as deferring to police conclusions.

She adds:  “Safeguarding work has to be cross professional and organisational boundaries and the task of developing and maintaining relationships is paramount. South Gloucestershire Council Adult Safeguarding acknowledges that they should have challenged some of the assumptions of the police, for example by pressing for fuller explanations of decisions. As their concern about such decisions increased, these should have been referred to the Safeguarding Adults Board for multi-agency consideration.” (4.16)

This SCR has clear policy implications – for example about ‘out of area’ placements and hospital assessment overall – but for social work practice there are multi-faceted messages. One of these is the importance of talking to people directly affected by the abuse and their families.

Flynn concludes about the families of patients who were abused at Winterbourne View: “The families no longer regard professionals as the bearers of legitimate knowledge.” (Section 4, 1.2). This sentiment may be widely shared by other carers and family members – not just in learning disability user and carer groups.

The impact on practice

Three potential implications for social work practice could be drawn out from these trends.

1. Social work managers will continue to be required to compile internal management reviews and to respond to complaints, provide statements for coroners and other scrutiny. SCRs will not be common in the world of the White Paper and beyond, but will have a higher profile. Calling them ‘statutory’ will likely have the effect of increasing numbers and significance. Social workers need confidence that what they are writing, the structure and the detail are ‘fit for purpose’ – skills development and peer support could assist here.

2. While there is a strong reaction against paperwork, social work records will remain important. No other agency is likely to know what a social worker has said, seen or done.

3. Supervision and peer support around cases also need to be captured to convey the fine-grained decision-making in social work and the consideration of risk – especially risks of harm. Not all incidents will have clear evidence of harm and there may be complex interpretations about people’s ability to make their own choices.

Questions for practice



  • When changes in law are proposed, do we start to behave as though they were already enacted?
  • What could stop a blame culture developing around safeguarding adult reviews? How do we support colleagues and get support ourselves when practice is questioned?
  • Are reviews and inquiries good learning tools – or do they reinforce pessimism and risk aversion?

References and further reading

Department of Health (2012), Caring for our future: reforming care and support, London, DH

Equality and Human Rights Commission (2011) Hidden in plain sight, Inquiry into disability-related harassment, London

Flynn, M. (2012), Winterbourne View Hospital: a serious case review, South Gloucestershire Adult Safeguarding Board

Manthorpe, J. & Martineau, S. (2012), “In our experience”: Chairing and commissioning Serious Case Reviews in adult safeguarding in England, Journal of Social Work, 12(1): 84-89.

Manthorpe, J. & Martineau, S. (2011) Serious case reviews in adult safeguarding in England: An analysis of a sample of reports, British Journal of Social Work, 41(2): 224-241.

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