Should SCRs be mandatory when vulnerable adults are killed?

Calls to mandate serious case reviews when adults at risk are murdered fail to recognise there are other ways of learning lessons, finds Natalie Valios

Making serious case reviews mandatory when adults at risk are murdered was a key recommendation from the Equality and Human Rights Commission’s (EHRC) inquiry into disability-related harassment, which reported last month.

Unlike for local safeguarding children boards, there is no national statutory guidance for safeguarding adults boards as to when SCRs should take place. The nearest equivalent is the protocol guidance from the Association of Directors of Adult Social Services, although this is voluntary and unmonitored.

Mike Smith, lead commissioner on the EHRC’s inquiry, says the reason behind its call was to “kickstart the debate”. “We want agencies to come up with a new framework for when a serious case review should or shouldn’t happen. What is needed is better guidance on if, when, why and how they are done. The current system has clearly failed people so we need some kind of change.”

The EHRC will now consult stakeholders on its recommendations and plans to publish a manifesto for change in spring 2012. But, although it has certainly got people talking, no one seems to be in agreement with the watchdog on SCRs.

Michael Preston-Shoot, independent chair of Luton’s safeguarding adults board, is one dissenter: “Boards look for the most effective and efficient way of learning lessons from serious cases and some are not convinced that SCRs are the best way. There may be situations where SCRs aren’t being held but other ways of learning lessons are being explored instead. The picture is more complex than the commission suggests.”

With the government confirming this year that safeguarding adults boards will finally be put on a statutory footing, Preston-Shoot says what is needed now is “to give boards the powers to drive forward effective safeguarding in their localities; to make sure that they are adequately resourced; and that there is a duty to co-operate, share information and inquire into cases that possibly involve adult protection”.

“Boards need to explore and learn from serious untoward incidents but I wouldn’t prescribe that it has to be an SCR. There are a number of ways of inquiring deeply into a case that might reveal individual or systemic failings,” he adds.

Pete Morgan, chair of the Practitioners’ Alliance for Safeguarding Adults UK, agrees: “An SCR is a specific tool to look at issues of multi-agency learning; the commission’s recommendation doesn’t recognise that at all.

“We have to be clear on what an SCR is about and what it should not be about. It shouldn’t be a PR sop to keep elected members and the press happy because something has happened. SCRs are one of a range of means of learning from practice. That should be happening all the time – and that’s learning from things when they go right as well as wrong.”

SCRs take substantial time and resources and should be rare occurrences, says Jill Manthorpe, director of the social care workforce research unit at King’s College, London. “If an incident has been reviewed by, for example, the police, a criminal court, the coroner’s court, the Health & Safety Executive, or the Care Quality Commission it won’t necessarily warrant a serious case review as well.”

Occasionally it will, as in the cases of the murder of Cornwall learning disabled man Steven Hoskin in 2006 and the Winterbourne View abuse scandal, whose SCR is in progress. Manthorpe says: “With Winterbourne the SCR will be looking at safeguarding and there will have to be a clear division so that it doesn’t interfere with the judicial process.”

The high profile around Winterbourne View raises another argument for not making SCRs mandatory and instead using other, low-key methods which are less likely to be picked up by the media: because they are becoming synonymous with assigning blame rather than a process for learning.

Cathie Williams, adult safeguarding lead at the Local Government Group, says: “The experience with children’s SCRs and how the media has responded to high-profile cases has made the process become embedded in people’s psyche as something that is punitive rather than about learning.

“Just to have an SCR when something has gone wrong may not be the only way. For example, I know of a couple of boards that review a few cases in great detail each year so they know what they are doing well or not, and this puts learning from successes and mistakes into a routine practice.”

As much as there is general consensus that SCRs should not be mandatory, there is also agreement that they do need a more structured framework for monitoring and dissemination so that lessons can be learned.

“You could mandate that each board has an agreed and demonstrable process for undertaking SCRs, but you couldn’t insist that each one implements it in the same way; they would have to be able to have their own template,” says Morgan.

“Once you have that in place then you can have a national database or collation process to hold executive summaries and recommendations so that professionals can learn from them.

“A central register would mean we could see which areas are undertaking SCRs and which aren’t, so we could find out why. This way we could get a consistency in process and procedure and find out patterns on a national basis.”

The idea is greeted enthusiastically by practitioners. Trudy Burns, a learning disability social worker and spokesperson for the College of Social Work, says: “Having the executive summaries and recommendations from serious case reviews in one place would be perfect. I don’t feel that familiar with them because the information isn’t widely distributed so unless you keep trawling the internet you don’t know where they have taken place.”

This lack of accessibility means that she has been exposed to SCRs as case examples only during training: “If we could get to the information quicker and easier, while keeping confidentiality, then any call for that would be good.”

Richard Pearl, a social worker for the older people team at Swansea Council, has never seen a serious case review. But he thinks being able to access them could have a positive impact on practice.

“It would be useful to know where you can find them, see what has happened, and the conclusions that have come out to improve your own practice,” he says. “We are often working with cases where something hasn’t yet taken place; a serious case review is the benefit of someone else’s hindsight and seeing that might make you think about doing something else that could keep someone safer.”

When to hold an SCR

Adass guidance on serious case reviews recommends that all safeguarding adults boards agree an SCR protocol.

It suggests that SCRs could be considered when: a vulnerable adult dies and abuse or neglect is a known or suspected factor; when there has been a serious incident; or when abuse takes place in an institution or when multiple abusers are involved.

The purpose is not to reinvestigate or apportion blame but to establish whether there are lessons to be learned; to review the effectiveness of procedures; and to inform and improve local inter-agency practice.

As safeguarding adults boards are multi-agency, SCRs are widely considered to be inappropriate when an incident involves a single agency. Instead, an internal review is generally undertaken.

But even when there is multi-agency involvement, boards often choose to use alternative methods to look at the processes, events and chronology surrounding a case with a focus on what might be learned.

This can include inquiries, action learning reviews, case file reviews, and learning through discussion between agencies.

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