Our Annual Analysis of SAR learning 2023-24

4 New Notifications were received       

Notification is the term for those cases notified to the Board that may meet the criteria for a review. Two other notifications were received in the previous period making six in total to be triaged.

One notification was received March 2024 and so will need to be triaged during 2024/25. ‘Triaged’ means the giving of consideration as to whether there is a reasonable belief in the potential for the legal criteria to be met. 

5 Notifications Triaged      

This includes one received in the previous period

3  Notifications Scoped      

Scoping involves the next stage of seeking additional information from wider organisations to inform the decision as to whether an SAR is required. 

0  SARs Commenced           

During 2023/24, none of those notification scoped were then deemed to meet the legal criteria. As such no new SARs have been commissioned in-year.

2  SARs Completed              

Two SARs that commenced within previous reporting periods were concluded during 2023/24.

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3 - West Yorkshire Police*                                                                                                                         1 - Basis                                                                                                                                                     1 - Leeds city council: Adults and Health                                                                                                 1 - Leeds Community Healthcare NHS Trust                                                                                           1 - Leeds City Council: Children Social Work Services (CSWS)

* One was also made by CSWS

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In relation to those three cases scoped, the principle reasons for the legal criteria not being met were:

• In one case there was insufficient indication that organisations had not worked together to safeguard the individual. The issue of working together is a key factor as it is this that would be the focus of any SAR undertaken.                                                                                                                                                                                
• In two cases the person died whilst exhibiting self-neglect behaviour, however it was neither ‘known or suspected’ to be the cause of their death. This means that the legal duty was not met and there was insufficient evidence to indicate that a review would gain additional learning to that already being achieved.

In a new process approved by the Board in April 2023, even where a Safeguarding Adults Review is not undertaken agency assurances may be sought by or on behalf of the Board by the SAR sub-group.  In each case scoped there was at least one subsequent assurance sought. The seeking of assurances does not imply any fault on the part of any organisation, it may only involve a request for information. The following learning points however arose from this process.

• Think Family, Work Family approaches (in two cases)
• Professional curiosity (in two cases)
• Use of telephone assessments
• Agreement of actions between agencies
• Planning for hospital discharge where safeguarding concerns have been raised
• Contact/involvement with referrers
• Safeguarding/care management responses

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This is a new process which has already evidenced its value, and in particular where joint responses have been requested from organisations. Highlights include a detailed action plan between Adults & Health and Children Social Work Services around joint working based upon Think Family, Work Family principles; and the development of an Adults & Health learning briefings for staff. There have also been helpful joint responses from Housing Leeds and Adults and Health around the issue of agreed actions.

Whilst extremely valuable as an approach, the assurances provided have been inconsistent in timeliness and the depth of information provided. Whilst this has prolonged the assurance process being undertaken it simply reflects the need to embed the new approach. In support of this the SAR sub-group are developing new templates which will provide greater clarity around what the assurances being sought.

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