Safeguarding Adults Review: Policy and Procedure

The responsibility to undertake Safeguarding Adult Reviews is set out in Section 44 of the Care Act (extract from the legislation):

44. Safeguarding adults reviews

(1) An SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—

(a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and

(b) condition 1 or 2 is met.

(2) Condition 1 is met if—

(a) the adult has died, and

(b) the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

(3) Condition 2 is met if—

(a) the adult is still alive, and

(b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.

(4) An SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

(5) Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to—

(a) identifying the lessons to be learnt from the adult’s case, and

(b) applying those lessons to future cases.

The Care Act therefore identifies the clear circumstances under which the Board must undertake a Safeguarding Adults Review, (a mandatory review) and also provides for the ability to conduct a review where the previous criteria are not met, but where the adult(s) has care and support needs and the Board identifies that there is potentially benefit in undertaking a review (a discretionary review).

It is important to be clear that both are statutory review processes conducted under the Care Act (2014); one is mandatory, the other discretionary. The LSAB is allowed to conduct a discretionary review in any other situations involving an adult in its area with needs for care and support, where important learning points may be apparent. The Board will consider all such situations on a case by case basis.

The requirements set out in the Care and Support Statutory Guidance issued under the Care Act (2014) apply to all Safeguarding Adults Reviews as do the content of this policy and procedure.

The LSAB may not conduct any other form of case review concerning individual citizens.

• Care and support needs

In the context of this policy and procedures, adults who have, ‘care and support needs’ are those people over 18 years of age, who require assistance with aspects of their day to day living as a result of a physical or mental impairment or illness, (including a mental health condition or substance misuse).

In respect of all reviews undertaken by the LSAB, there must be, therefore ‘reasonable cause to suspect’ the person has needs for care and support, whether or not they have received services to meet those needs.

• Serious abuse and/or neglect

In the context of application of these criteria, ‘serious abuse’ and/or ‘neglect or self-neglect’ is defined within the statutory guidance as including, ‘where the person would have died but for intervention, or where they have experienced permanent harm or reduced capacity or quality of life’.

All mandatory Safeguarding Adults Reviews undertaken by the LSAB must concern an adult who died or experienced ‘serious abuse, neglect’ or self-neglect in Leeds.

• Working together to safeguard adults at risk

The test for consideration of how effectively, ‘the SAB, members of it, or other persons with relevant functions worked together to safeguard the adult’ is one of ‘reasonable cause for concern4’.

The overarching objective of a Safeguarding Adults Review is to learn from people’s safeguarding experience and circumstances to inform and influence the ongoing development of excellence in safeguarding adults systems and practice in Leeds.

The Care and Support Statutory Guidance, issued under the Care Act (2014) is absolutely clear on this matter, stating that, ‘SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again’5.
In Leeds, Safeguarding Adults Reviews explicitly consider how effectively the safeguarding has system has worked to safeguard a person by using the review as a ‘window on the system, not a search for root causes.6’ A Safeguarding Adults Review is not an investigation.

The purpose of conducting a SAR is to:

• Establish whether there are lessons to be learnt from the circumstances of the case about, for example, the way in which local professionals and agencies work together to safeguard adults at risk.
• Review the effectiveness of procedures and their application (both multi-agency and those within organisations).
• Inform and improve local inter-agency practice by acting on learning and developing evidence-based best practice, in order to reduce the likelihood of similar harm occurring again.
• Bring together and analyse the findings of the various reports from agencies in order to make recommendations for future action.

It is essential that all safeguarding agencies in Leeds are clear and communicate to their staff that:

a. It is not the role of a Safeguarding Adults Review to hold any organisation to account;

b. A Safeguarding Adults Review is not an escalation of the operational multi-agency safeguarding adults procedure;

c. A Safeguarding Adults Review primary purpose is systemic learning; it is not about blaming individual practitioners.

Other processes exist for these purposes, including the Leeds multi-agency safeguarding adults procedures, criminal proceedings, disciplinary procedures, statutory employment processes and systems of service and professional regulation, such as those regulated by the Care Quality Commission, the Nursing and Midwifery Council, Social Work England, the Independent Police Complaints Commission and the General Medical Council.

The LSAB understands that participation in a Safeguarding Adults Review may be potentially challenging for agencies, but in Leeds, it is absolutely intended as a positive, reflective process, where good practice is highlighted and shared. It is not one of blame, punishment or accountability.

The Leeds Safeguarding Adults Board is the only body that can commission a Safeguarding Adults Review, arrange for its conduct and, if it so decides, to oversee implementation of the findings.

The duty described above is for the Board and it is collectively responsible, therefore for all decisions made in respect of the SAR, including its terms of reference and the way in which the findings are handled.

While the LSAB provides a process for agencies to refer a notification of a person’s circumstances that may meet the criteria for a Safeguarding Adults Review, this is not necessarily required. If the LSAB becomes aware of a citizen of Leeds whose circumstances potentially meet the criteria for a Safeguarding Adults Review at s44 Care Act (2014), it must seek information about that person and their circumstances, with a view to applying those criteria, regardless of any referral or notification being made.

The Local Government and Social Care Ombudsman, (LGSCO) has responsibility for investigating complaints about the decision-making of Safeguarding Adults Boards (SABs), and has made judgements against several SABs as a result of the lack of clear and appropriate decision-making in line with legal duties and the principles of good administrative practice9. The decision-making process set out in the procedures section of this document is fully compliant with those principles.

All Safeguarding Adults Reviews conducted in Leeds have an associated SAR Framework Document. This will be authorised by the Independent Chair at the start of every SAR, ensuring all concerned are clear about the mandatory / discretionary status of the SAR, the agreed Terms of Reference, the agencies involved, the methodology, any parallel processes and provisional timescales for action. The SAR Framework Document allows the Board to assure itself on a regular basis of the progress of the SAR.

The LSAB is required by law10 to publish the findings from any SAR in its Annual Report, setting out the actions it has taken, or intends to take in relation to those findings. If the LSAB decides not to implement an action, then it must state the reason for that decision in its Annual Report.

The Care and Support Guidance issued under the Care Act (2014) refers to the importance of timeliness in conducting reviews, requiring boards to complete a SAR within six months of its initiation, ‘unless there are good reasons for a longer period being required; for example, because of potential prejudice to related court proceedings’.

All documentation the LSAB receives from registered providers which is relevant to CQC’s regulatory functions will be provided to the Care Quality Commission as legally required12.

The LSAB is committed to openness and transparency in its governance and there will always ensure that the learning from SARs is accessible and openly available to citizens in a range of different formats.

People’s lives do not necessarily fit with our organisational or legal structures. It is therefore important that the LSAB is aware that other statutory review processes may also apply to a person’s circumstances when considering a Safeguarding Adults Review.

Where it makes sense and achieves the best learning for the city, the LSAB will conduct joint reviews with other partnerships, ensuring that the Board is provided with clear supporting working agreements for approval as necessary.

Examples of possible related reviews include:

• Child Practice Reviews
• Domestic Homicide Reviews
• MAPPA Serious Case Reviews
• Mental Health Homicide Reviews
• NHS Serious Incidents
• LeDeR Reviews

A LeDeR Review, ‘Learning from lives and deaths – People with a learning disability and autistic people’ is a process undertaken by the NHS, although reviews can also involve information from other agencies. The LeDeR process was formerly known as the Learning from Deaths Review Programme, which started in April 2017 and developed from the Confidential Inquiry into Premature Deaths of People with a Learning Disability (CIPOLD).

The LSAB participated with a neighbouring SAB’s s44 SAR in 2019 because the person concerned had some involvement with Leeds. The person concerned had a learning disability and a LeDeR review was undertaken. The neighbouring SAB questioned the most effective way to undertake the SAR process and asked whether the two processes could be combined. Advice was sought from NHS England, which advised, ‘a SAR always takes priority due to its statutory status. A LeDeR review is not a mandated review and as such no statutory responsibilities currently exist for it’. It was suggested that there were parts of the SAR process that could, however, be shared with the LeDeR review, such as liaison with family members, but they are distinct processes with a SAR taking precedence.

The LSAB will always work with the LeDeR review process as needed, ensuring that maximum learning is achieved, ensuring this achieves any necessary improvements.

There may be criminal or coronial investigations running concurrently with the SAR. The LSAB will ensure that any of its activity in relation to a Safeguarding Adults Review does not prejudice criminal or judicial proceedings through early discussions as necessary with West Yorkshire Police, HM Coroner and the Crown Prosecution Service.

It may also be necessary to delay the publishing of an overview report until the conclusion of any criminal trial. If this is the case, the LSAB will endeavour to ensure that learning is acted upon at an early stage and necessary changes are not impeded.
Individual agencies can, and will be asked, however, to progress with implementing the review learning.

Agencies may also have their own internal or statutory review procedures to consider serious incidents. This policy and procedure are not intended to replace those in any way. Where the LSAB has decided to undertake a SAR, agencies are asked to share their learning and any reports to support that process.

Safeguarding Adults Reviews do not form a part of any agency’s employee disciplinary process. Should information emerge in the course of the SAR that may indicate that disciplinary action may be appropriate, the agency concerned should deal with such issues in accordance with their own procedures. If disciplinary matters are in progress at the commencement of the SAR, these should be notified to the Board Manager in order that the SAR can ensure that matter is handled with care; all such information will be handled with sensitivity and in line with GDPR principles.

The local authority may also have conducted a s42 Care Act enquiry. Where this is the case, that information may inform the Board’s decision-making. The Board should exercise care to ensure that its decisions are based upon analysis of s44 criteria and not those being addressed within the enquiry. The purpose of a s42 enquiry is to identify individuals at an operational level who are experiencing or are at risk of abuse or neglect, in order to formulate a plan to safeguard them from this. The duty is therefore different from that at s44, where there is strategic consideration of how Board member agencies and others work together in order to prevent future incidents.

A Safeguarding Adults Review should be undertaken in the area20 where the person, ‘died’ or ‘experienced serious abuse, neglect or self-neglect’.

Where a person who has been known to services in Leeds is subject of an SAR in another area, Leeds agencies that had known that person will be subject to the Care Act requirement at s45 of the Act that information is supplied in order to enable or assist, ‘the SAB to exercise its functions’.

Where Board member agencies are approached for provision of information for an out of area SAR, they are asked to:

• Advise the LSAB Independent Chair of this request;
• Copy the LSAB into any relevant correspondence; 
• Share any learning they have achieved through the process that may be of relevance to safeguarding adults in Leeds.

The LSAB Independent Chair will also ask the host SAB to share relevant learning with the LSAB to ensure it is acted upon within Leeds.

It is important that SAR recommendations are informed by local knowledge. For this reason, emergent recommendations will be discussed at all stages of the SAR process, including, when the SAR has a Panel, at their meetings and at practitioner events. Independent Reviewers will also make recommendations as a part of the SAR process. While recommendations are therefore developed locally, they will also have been developed with independent challenge, knowledge and expertise through the Independent Reviewer(s)’s input.

Effective sharing of the learning achieved in any review is essential; in Leeds, this is based on both learning from identified development needs and also from good practice identified in the review.

As noted previously, the LSAB is required to publish all Safeguarding Adults Reviews it has undertaken in its Annual Report, explaining the review findings and identified learning points and review recommendations. The Board will also set out its plan to act on those areas of learning and recommendations.

The LSAB will always be asked to review and subsequently agree the content and progress of both individual and multi-agency learning action plans that result from a Safeguarding Adults Review. It is imperative that the Board ensures that real change and improvement results from any Safeguarding Adults Review and that it is able to demonstrate this through its learning, assurance and publication processes. Individual agencies are responsible for the dissemination of learning from Safeguarding Adults Reviews; the Board will always support agencies in doing so by providing briefing summaries, but all Board member agencies are expected to ensure that learning is shared with across their organisation once a SAR has been approved by the Board. Effective sharing of that learning within organisations will always be a recommendation from SARs in Leeds and will form part of each multi-agency Action Plan.

The statutory guidance states that the, ‘main objective of a SAB is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area’22. Safeguarding Adults Reviews and the assurance provided about the change and development that accompanies them are an important part of the Board’s approach to achieving that objective.

The LSAB will review individual and multi-agency responses to the SAR Action Plan and consider whether the information provided is sufficient to assure the Board that future arrangements will address the identified concerns.

Where the Board does not receive the assurance it needs from agencies in relation to a SAR Action Plan, then it will need to seek further assurance and Board members will need to discuss this matter at its meeting.

As detailed in the LSAB Safeguarding Adults Review Policy, Safeguarding Adults Boards have a legal duty to undertake a SAR when a person’s circumstances meet the criteria set out at Section44 Care Act 2014. The Safeguarding Adults Board must arrange for there to be a review of a case involving an adult in its area with needs for care and support, if there is:

i). reasonable cause for concern about how the Board members of it or other persons with relevant functions worked together to safeguard the adult, and

ii). the person had died as a result of abuse, neglect or self-neglect or they are alive but experienced serious abuse, neglect or self-neglect.

All agencies working in Leeds to provide care, support and protection to the city’s citizens have a responsibility to notify the LSAB when there is a possibility that a person’s circumstances meet these criteria. Similarly, where the Board becomes aware of such a situation, it is duty-bound to undertake enquiries and consider whether or not the person’s circumstances meet the statutory criteria.

Any member of the public or agency can notify the Board of a person’s circumstances that may meet the criteria for a Safeguarding Adults Review. A notification form is available for this purpose. This form is designed to enable the Independent Chair and Board members to reach a decision about whether or not to conduct a review. Where the person undertaking the notification is an employee of an agency that is a member of the LSAB, they should consult with their Board Member prior to submission.

When the Board becomes aware of a person’s circumstances that may meet the criteria for a Safeguarding Adults Review, whether through the receipt of a notification or in another way, the LSAB Strategy Unit, (Unit) will advise the Independent Chair. The Unit will also undertake an initial evaluation of the available information and where it is clear that the circumstances will not meet the criteria, for example because the person concerned died or the abuse took place in another SAB area, it will advise the Independent Chair.

The Unit will also liaise on behalf of the Independent Chair with Safer Leeds and the Leeds Safeguarding Children Partnership to discuss any linked review processes. It will also liaise with other processes that are referred to in Part 7 of the LSAB SAR policy.

Scoping involves making requests to agencies for essential information so as to understand the person’s circumstances to inform decision-making;

Where the person’s circumstances have the potential to meet the statutory SAR criteria, the Independent Chair will ask the Strategy Unit to make a request of agencies for essential information about the person’s circumstances to inform the Board’s decision-making

This request involves the Unit contacting all statutory agencies and any other services that are known to be involved in the person’s life / experience and asking them to complete an SAR Notification Essential Information Enquiry form. This document asks for information about the agency’s contact within a period of time relevant to the person’s circumstances. Guidance is provided to agencies for the completion of the form. This information is key in enabling the Independent Chair make a recommendation to the Board about whether or not to conduct a SAR.

Often there will be other information available to assist the Independent Chair and the Board in the decision-making process. This includes, but is not exclusive to any Section 42 enquiry undertaken by the local authority, a Serious Incident process from within the NHS or a commissioned service review undertaken following a death or serious incident.

The responsibility for deciding whether or not the statutory criteria are met is the collective responsibility of the whole Safeguarding Adults Board in Leeds.

Initially, however, the Independent Chair is asked to consider the information that has been collated by the Strategy Unit about a person’s circumstances and apply this to the statutory criteria.

When this has taken place, if the Independent Chair considers that the criteria are met for either a mandatory or discretionary SAR, they will report this to the LSAB, explaining their analysis and providing a draft Framework Document.

In order to facilitate a decision, in addition to the Framework Document and the proposal, the LSAB will be provided with a summary of the information considered by the Independent Chair. The nature of this information means that it will be provided in a summary form. The Independent Chair will authorise that summary to assure Board members of its accuracy and the absence of any unintentional influence or bias.

If the Independent Chair recommends that the LSAB should undertake a Safeguarding Adults Review, whether mandatory or discretionary, members will be provided with a draft SAR Framework, which includes its governance. Members will be asked to consider proposals for commissioning the lead reviewer(s), methodology, the draft Terms of Reference for the Review, draft Key Lines of Enquiry (KLoEs) and projected costs.

The LSAB will be asked to decide collectively whether or not the person’s circumstances meet the criteria at Section 44 Care Act (2014) as a mandatory or discretionary review or if the person’s circumstances are considered to not meet the criteria for a SAR. It is important that the Board is aware that it cannot propose or request any other form of review that is outside the provisions set out at Section 44 Care Act (2014).

Board members will be asked to explicitly consider the following questions that have been developed to enable careful and transparent consideration of the statutory criteria:

a) Does the person have a physical or mental impairment or illness, i.e. care and support needs?

b) Does the Board have reasonable cause for concern about how agencies worked together to safeguard the adult?
c) Does the LSAB know or suspect that the person’s death resulted from abuse or neglect?

Or

d) Does the LSAB know or suspect that the person experienced serious abuse or neglect?

In relation to questions c) and d), if the answer is positive, the type of abuse or neglect / self-neglect will be recorded.

The LSAB SAR notification and decision-making pathway is set out at Figure 1.

The Board will agree which methodology should be followed at the same time as it decides a person’s circumstances meet the criteria for a SAR. Different methodologies will suit different types of circumstances. These can range from facilitated learning events over a day or two, through to formal Panel-led over-arching type of enquiries carried out over a period of time. The choice of methodology will always be appropriate and proportionate to the case under review and will be clearly stated in the SAR Framework Document.

The Care and Support Statutory guidance states that, ‘The SAB should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases’26.

When the Board decides to appoint a Review Panel, this will comprise of relevant and nominated people who will contribute to and reflect on the information submitted to the Review.

The Review Panel size will be proportionate to the nature and complexity of the Review and its composition will be configured to bring relevant expertise in relation to the particular circumstances. The Panel will be chaired by the independent reviewer or, in exceptional circumstances a chair who is either commissioned separately or who is provided by a Board member agency that is not party to the Review.

The SAR Framework Document will always include the SAR Terms of Reference. These will be draft when initially provided to the Board and will be developed as necessary. The Terms of Reference will always include consideration of the person’s known wishes and feelings in relation to relevant matters and will require the review to address issues relating to the person’s culture, heritage and identity.

The Terms of Reference will also set out the focus and breadth of the SAR; the timeframe covered by the SAR, roles, expectations and anticipated outcomes with agreed timescales for completion.

The LSAB Strategy Unit is responsible for liaising with the other safeguarding partnerships in the city when there is a possibility that the criteria for a Domestic Homicide Review or a Child Practice Review may be met.

Where a joint SAR and other statutory review is undertaken, the LSAB will always require a Memorandum of Understanding to be established at the beginning of the process, to ensure good governance of the process and discussions will also take place between the partnership chairs about how to proceed with a joint approach that achieves the necessary learning and meets all statutory duties. These agreements will need to be approved by the LSAB.

Where any parallel processes take place, the LSAB Strategy Unit is responsible for ensuring effective communication and liaison.

Any report of a SAR undertaken in Leeds will:

• provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence, if possible;
• be written in plain English;
• contain findings of practical value to organisations and practitioners;
• identify learning points for development into an action plan by the Review Panel, which will be agreed by the Board.

The report will be fully anonymised, with the wishes and views of any family, relative or the person who is the focus of the SAR about the use of anonymised nomenclature.

The SAR Panel will be provided with the report and will ensure that contributing organisations and individuals are satisfied that their information is fully and fairly represented in the reports; that it represents the SAR process and findings and addresses the SAR Terms of Reference.

When this has been agreed, the SAR report will be shared with the full Board, which will be asked to approve the report.

In the interest of transparency and disseminating learning, the LSAB will always seek to publish the SAR Report whilst maintaining confidentiality for those involved as appropriate.

The SAR Report is the property of the LSAB and it is the LSAB’s decision as to whether and how it is published. However, if the person’s concerned, their family or others with a relevant role express a view that it is not published, this will be discussed with those concerned with care, exploring risks and with a view to achieving agreement.

All media interest will be handled by the Leeds City Council Communications Team on behalf of the Board. Agencies will always be involved in discussion about the media strategy and where appropriate, the City Council’s communication team will liaise with teams within those agencies.

The findings and actions from the SAR will be published in the LSAB Annual Report.
Published SAR Reports and Learning Briefings will be made available on the LSAB website for one year following publication. Copies will also be available via the national repository for SAR reports, the Social Care Institute for Excellence (SCIE) National Safeguarding Adults Review Library .