It can be difficult to understand / navigate the different types of enquiries, investigations and reviews that can take place where there are safeguarding concerns.

Here we set out the twelve most common ones, to show what they are, when they might take place, and how they link with safeguarding adults.

1. Section 42
2. SAR
3. Criminal Investigation
4. Internal Investigation
5. Disciplinary Investigation
6. Care Quality Commission (CQC)
7. Integrated Quality Team
8. Domestic Homicide Review (DHR)
9. LeDeR
10. Serious Incident framework
11. Coroner Investigations
12. Office of the Public Guardian (OPG)

1.   Section 42

This is the section of the Care Act 2014 where safeguarding adults duties are set out. It has become the ‘short-hand’ for a safeguarding adults enquiry or investigation.

Section 42 (s42) enquiries are led by the local authority (Norfolk County Council Adult Social Services) but are multi-agency in their approach.

When the need for an enquiry has been agreed by the local authority (LA), a multi-agency planning discussion will take place to decide what types of investigation or review are needed to address the concerns raised. Where these are not directly done by the LA, they will still co-ordinate; the outcomes will form part of the safeguarding adults enquiry overall, including conclusions and actions.

2.    SAR

A Safeguarding Adults Review (SAR) is an in-depth multi-agency review of a case where an adult at risk (with care and support needs) has died or come to serious harm, because of a safeguarding issue, and where it appears the agencies involved could have worked together better.

A SAR is commissioned by the Safeguarding Adults Board. It is very different to a s42 enquiry.

A SAR is about learning lessons and preventing the same thing from happening again. It is not an investigation; it does not apportion blame. It will usually happen after a s42 enquiry has taken place. More information can be found on our Safeguarding Adults Review page.

3.    Criminal Investigation

Where it looks like a crime may have been committed, the police have the lead duty to investigate. Where this happens as part of a safeguarding enquiry, the criminal investigation will have priority, but the LA still has the duty to lead the overall s42.

The safeguarding planning discussion must include any action agreed by police, and consider what other actions to safeguard the individual (or other potential victims) may be needed. Other agencies involved should support the police as required.

An important note here – where one agency carries out its own enquiry e.g. internal / disciplinary before the police have started or finished the criminal one, that agency runs the risk of impeding / interfering with police due process. This can lead to loss of evidence or first accounts, meaning that in some cases prosecution is then not possible.

Therefore all involved parties need to establish from the start what they can or cannot do while the police investigation is in progress.

The social care worker leading the s42 must liaise regularly with the police, supporting the co-ordination of updates and any other actions that are needed as the criminal enquiry progresses.

4.    Internal investigation

This means a single agency led investigation / enquiry done by an organisation or agency into its own actions or employees. This can include disciplinary investigations depending on the circumstances.

These will not always relate to safeguarding issues / enquiries, but where there is a s42 in progress, the person leading this for the relevant organisation will have been requested to do so by the LA following the safeguarding planning discussion. The outcome must be reported back to the LA where it can be incorporated into the s42 enquiry, and any further action decided.

5.    Disciplinary Investigation

This is a single agency led investigation into the actions of a specific employee, under the contracted employment terms of the organisation. It is usually completed by a relevant person in that organisation, and there are formal processes to follow.

This can also include professional misconduct enquiries for example the Nursing and Midwifery Council (NMC) would investigation allegations against nursing staff, Health and Care Professions Council (HCPC) health and care professionals, General Medical Council (GMC) doctors, Independent Police commission (IPC) police officers.

These investigations focus on the legal and moral expectations on professional staff (Codes of Conduct for example), checking that these have been met by that person. It can lead to de-registration.

Disciplinary investigations do not always involve safeguarding issues, but where they do, the organisations need to ensure that these have been reported properly, safeguarding process considered, and link into s42 enquiries in the same way as internal investigations.

6.    Care Quality Commission (CQC)

The CQC monitor, inspect and regulate care and health services to make sure they meet certain standards of quality and safety. They visit and inspect care and treatment settings and services, such as care homes, hospitals, GPs, dentists, mental health settings.

A ‘regulated’ service means it carries out a prescribed activity related to care and treatment (set out in the Health and Social Care Act (Regulated Activities) Regulations 2010). Quick reference guide to regulated activities by type of service | Care Quality Commission (cqc.org.uk)

They will look at services as a whole, but an Inspection may be prompted by safeguarding concerns raised about a person or people within that service. They gather information from the services themselves, service users, family, professionals and members of the public. CQC have the power to limit or de-register services that other agencies do not. Their inspections and any actions will run parallel to any s42 enquiry, and the Inspector for a specific service should be involved in safeguarding planning discussions and meetings where relevant.

7.    Integrated Quality Service

This is an integrated health (NHS Norfolk & Waveney) and social care (Norfolk County Council) quality monitoring team covering care services they commission (arrange and pay for) or that are registered as care providers in Norfolk. They cover residential and nursing care, home (domiciliary) care, day services, supported living, whether funded by adult social care or continuing health care.

The Quality Monitoring Officers carry out regular visits to the various services and assess the quality of care being delivered using Provider Assessment and Market Management Solution (PAMMS). They then work with services to address any gaps identified. This links to the prevention part of safeguarding, by finding quality issues that might lead to poorer quality care and organisational safeguarding. Like CQC, the IQS work in parallel to safeguarding processes but can also offer more directed support to address safeguarding concerns so should be involved from the outset in s42 enquiries around registered care services.

8.    Domestic Homicide Review (DHR)

A DHR is a locally conducted multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse, or neglect by:

• a person to whom he or she was related, or with whom he or she was or had been in an intimate personal relationship; or
• a member of the same household as himself or herself (section 3.8 DHR statutory guidance)

Their purpose is not to reinvestigate the death or apportion blame, but to learn lessons and see these lessons acted on, improving multi-agency working to prevent domestic violence homicide and improve responses to victims (including their children).

DHRs are not specifically part of any disciplinary enquiry or process. Where information emerges in the course of a DHR indicating that disciplinary action should be initiated, the established agency disciplinary procedures should be undertaken separately to the DHR process. Alternatively, some DHRs may be conducted concurrently with (but separate to) disciplinary action (section 3.5 DHR guidance).

More information Domestic Homicide Reviews (DHRs) | Norfolk Community Safety Partnership

9.    LeDeR

The learning from deaths of people with a learning disability (LeDeR) programme was set up as a service improvement programme to look at why people are dying and what can be done to change services locally and nationally to improve the health of people with a learning disability (LD) and reduce health inequalities. By finding out more about why people with LD died we can understand what needs to be changed to make a difference to people’s lives.

LeDeR is led by health (although can include other partner agencies) and is now part of the NHS Norfolk and Waveney Integrated Care Board work.

In a LeDeR review someone who is trained to carry out reviews (usually someone who is clinical or has a social work background) looks at the person’s life and the circumstances that led up to their death. They look at the GPs records, social care and hospital records (if relevant) and speak to family members about the person who has died to find out more about them and their life experiences. Using this information, they can make recommendations to the local commissioning system about changes that could help improve services for other people with LD.

A LeDeR review is usually separate to a s42 enquiry, as it considers any death, but where suspected abuse is identified the reviewer may refer for a SAR (where there are lessons to be learnt in the safeguarding system) or s42 (where risk of harm / abuse is still active). A LeDeR review may be paused if there is active safeguarding investigation taking place.

In March 2021, NHS England and Improvement (NHS E/I) published the “Learning from lives and deaths – People with a learning disability and autistic people” policy 2021 (‘the LeDeR Policy’), now including people with autism.

NHS England » Learning Disability Mortality (death) Review programme

10.    Serious Incident Framework

This relates to NHS healthcare (including community settings), and is a single agency led process. These internal investigations look at situations where there has been unexpected or avoidable death, serious harm, or abuse at a point where NHS funded care was being provided, or where healthcare didn’t take appropriate action or intervene to prevent the abuse happening.

Serious Incidents (SIs) are investigated to identify learning and prevent things from happening again. When an SI has been identified, immediate action is taken to determine the facts and consider patient safety as a priority.

SIs will not always relate to the abuse of adults at risk, but where they do, they must be reported as a safeguarding concern so the LA can decide if a s42 enquiry is also needed, as the two investigations have a different focus (a s42 may determine fault, an SI is to find any learning to support prevention).

NHS England » Serious Incident framework

11.    Coroner Investigations

When most people die, their death certificates are completed by health professionals who agree what the cause of death was. This is not always possible; so the coroner will investigate deaths that have been reported to them where:

• the death was violent or unnatural
• the cause of death is unknown
• the person died in prison, police custody, or another type of state detention (including deprivation of liberty)

Coroners must make legal enquiries to find out very specific things:

• who the person is
• how, when, and where they died
• any specific detail required to register the death

If it is not possible to find out the cause of death from a post-mortem examination, or the death is found to be unnatural, the coroner must hold an inquest.

An inquest is a public court hearing held by the coroner to establish who died and how, when and where the death occurred. The coroner (or jury if one is involved) can make ‘findings’ to allow the cause of death to be registered, such as ‘accident or misadventure’, ‘natural causes’, ‘unlawful killing’, ‘suicide’ or an ‘open’ verdict. The coroner or jury may also make a brief narrative conclusion setting out the facts surrounding the death in more detail and explaining the reasons for the decision. 

Coroners | The Crown Prosecution Service (cps.gov.uk)

12. Office of the Public Guardian (OPG)

The OPG helps people in England and Wales to stay in control of decisions about their health and finance and make important decisions for others who cannot decide for themselves. They carry out the legal functions of the Mental Capacity Act 2005 and the Guardianship (Missing Persons) Act 2017.

They help people plan for someone else (a Lasting Power of Attorney (LPA), deputy or Guardian) to make decisions for them, if that person is unable to because they do not have mental capacity and support the LPA in making those decisions where necessary.

Where there are concerns about the LPA, or reports of abuse by the LPA, the OPG will make enquiries about their conduct, actions, or management of financial affairs. They can then apply to the Court of Protection applying to the Court of Protection to suspend, discharge or replace a deputy and to cancel or revoke an LPA. They also provide reports to the Court of Protection under sections 49 and 58 of the Mental Capacity Act 2005, to help the court make informed decisions.

Office of the Public Guardian safeguarding policy