Why we do reviews: Please tell us about their 'impact and reach’

Estimated reading time 7 minutes.

At the National Safeguarding Adults Board managers meeting in March, we were joined by Tom, the subject of a Safeguarding Adult Review (SAR) by the West Sussex Safeguarding Adults Board. 

Tom’s presence was a unique opportunity to talk directly with someone about what it was like to be the focus of a SAR (sadly, most subjects of reviews have died and so instead we try hard to ‘hear their voice’ with the help of family and friends). 

So it was incredibly impactful, powerful and moving to hear Tom’s experience. We are all incredibly grateful to him for giving his time so generously, his open and candid reflections, and the advice he shared about being involved in a SAR.

Thank you, Tom. Also, my thanks to Ru and Aimee from West Sussex Safeguarding Adults Board for supporting Tom in the lead-up to and during the meeting.

You can read the Safeguarding Adults Review, learning briefing and podcast about Tom here. If you can, do have a look as the learning from Tom’s experience speaks to all involved in adult safeguarding.

In the days since this meeting, I have been thinking a lot about Tom, the review work we do and why is it important. 

A regular commentary on SARs in Norfolk (and I am sure for other SABs as well) is that the same issues to support safeguarding system change and improvement keep coming up each time. The lessons are the same, so why are we doing yet another review? It is  a good question to ask. I think there are two critical points to keep in mind:

• The legal requirement to carry out a SAR when the criteria are met
  
  
• At first glance, the learning topics may look the same (i.e. the assessment of mental capacity as it interfaces with safeguarding; professional curiosity; the sharing of information), but every case is unique and tells us something new – this is a unique person and family with a unique story
  
  
• Perhaps we need to reframe the response, from ‘we already know what the issues are’ to ..  ‘why are these issues still presenting in our local system?’ 

What is a Safeguarding Adults Review?

Safeguarding Adults Reviews (SARs) are conducted to examine cases where an adult with care and support needs has died or suffered serious harm due to abuse or neglect, and where there are concerns that agencies could have worked more effectively to prevent the harm. SARs are a statutory requirement under the Care Act 2014, which mandates that SABs must arrange a review if certain criteria are met. These reviews are not about assigning blame, but about identifying lessons to improve future safeguarding practice.

SABs also have the discretion to carry out SARs in other circumstances where learning could improve safeguarding practices. The aim is to ensure that organisations involved in adult safeguarding identify systemic issues, strengthen multi-agency working, and improve responses to future safeguarding concerns.

The SAR is the conduit for contributing to greater transparency and public confidence in safeguarding processes by ensuring accountability and learning from past cases. SARs highlight areas for improvement and also best practices, helping professionals develop a more effective and coordinated approach to adult safeguarding.

Furthermore, SAR findings influence policies, procedures and training at local and national levels, ensuring that safeguarding frameworks remain robust and responsive. By fostering a culture of continuous learning and improvement, SARs ultimately enhance the protection and well-being of vulnerable adults, helping to prevent similar incidents in the future. 

However, as a very experienced and trusted senior SAB colleague said recently, it takes 17+ years to see systematic change, so we have to ‘keep on keeping on’. As Confucius said:

‘It does not matter how slowly you go as long as you do not stop’ 

I also find it helpful to remember what Nelson Mandela said:

‘It always seems impossible until it's done.’

Recent SARs published by Norfolk SAB: SAR Eric and SAR Adult X 

Eric was in his early 60s and went into residential care when he became unable to remain safely at home. This was due to self-neglect, depression and self-harm, and a dementia-type presentation, which was presumed to be related to his history of alcohol dependency.
But Eric found it very difficult to settle into the care homes he was placed in, partly because the other residents were older and/or more dependent than he was. He became even more unhappy and eventually died by suicide. Findings from this review reflect the need for more individualised resources, greater understanding of less common conditions such as Korsakoff dementia, and professional curiosity about people who do not easily engage with professionals or services. Understanding and appropriate use of the Mental Capacity Act was also a key theme. 

SAR Adult X involved an older man (in his 80s) released from prison after serving his sentence for serious sexual offences. He was initially discharged into Approved Premises, but then went into hospital. When his care and support needs increased, the accommodation could not take him back. He ended up in hospital for many months longer than needed due to the difficulties finding a suitable care environment. There were also significant issues in the multi-agency public protection meetings, complicated by cross-border factors. 

You can read more about Eric and Adult X on our website here.

For each review we create a range of materials to support the widest possible audience to use the learning in their everyday safeguarding work. The NSAB business team are very mindful of how this material is put together, to ensure it is as useful as possible to the frontline.

Some recent feedback told us that:

• the structure, format and layout is helpful and useable
  
  
• organisations ‘lift and shift’ this information into their internal comms pathways (intranet / newsletters / staff briefings / specific safeguarding meetings or forums / staff training etc)
  
  
• there is a key role everyone including our senior leaders to help promote this learning material in their organisations, promoting a point that this is learning can carry some extra ‘importance’ as it is from our system

We continue to work on the content of this material, for example to ensure it has a specific relevant/pertinence to a particular sector or part of the workforce. Future SAR learning materials will include ‘learning outcomes’ and prompt questions that can be used by staff.

Have you used NSAB material in the last year? 

With regards to the SAR learning and other material we have shared, you and your colleagues can be big help to us. Have you used it in the last year? Please tell us!  Our annual NSAB survey is now LIVE.

It takes just a few minutes to fill it in and it would be great to have as many returns as possible for this year’s annual report. This year with your help we could reach 1,000+! 

NSAB has a new chair

A warm welcome to Natalie Cowland, who takes Heather Roach’s place from the beginning of April. Natalie comes to us from the
Nursing and Midwifery Council, where she was head of organisational learning, quality and improvement.

Before this, Natalie had a 30-year career with the Metropolitan Police Service (MPS), including a significant background in multi-agency collaboration, with 15 years' strategic experience across policing and regulatory health settings. She has worked in safeguarding settings at every level, leading teams dealing with complex adult protection investigations, leading MPS’s response to all statutory safeguarding reviews, including SARs, with the Continuous Policing Improvement Command and with National Counter Terrorism.

I know Natalie is keen to meet as many colleagues as possible in the coming months.

Thank you.

Walter Lloyd-Smith

Norfolk Safeguarding Adults Board Manager

Good News

PLUS here is a very good thing … a reminder of the new legislation around cuckooing (see link below) New legislation around cuckooing offences - read more here: Crime and Policing Bill: Child criminal exploitation and 'cuckooing' factsheet  - GOV.UK