5.5 Safeguarding Adults Review (SAR) Policy: Conducting SARs in Bury

1. Introduction and Purpose of Policy

The Care and Support Statutory Guidance states that in order to achieve the aims of safeguarding, it is important to ‘support the development of a positive learning environment across partnerships and at all levels within them to help break down cultures that are risk-averse and seek to scapegoat or blame practitioners’.

One of the core duties of a Safeguarding Adults Board (SAB) is to review cases where an adult with needs for care and support has died and the death resulted from abuse and neglect, or is alive and the SAB knows or suspects that they have experienced serious abuse or neglect.

Importantly, Safeguarding Adult Reviews are about how agencies worked together to safeguard adults; they are in their nature multi-agency reviews. For a review to be mandatory in legislation, there must be reasonable cause for concern about how the SAB, its members (or others with relevant functions) worked together to safeguard the adult.

This chapter sets out the arrangements by which Bury Safeguarding Adults Board (BSAB) will conduct case reviews. It highlights the statutory duties, overall process for running a Safeguarding Adults Review (SAR), and how the SAB will commission such work.

This policy outlines the process for the management of Safeguarding Adults Reviews (SARs) in Bury under Section 44 of the Care Act 2014. It has been developed to simplify and clarify the local process by:

• providing an overview of how to notify the SAB of serious incidents which may be suitable for a SAR;
• enabling a consistent approach to SAR decision making and practice;
• demonstrating how local processes comply with legal requirements and best practice;
• clarifying SAR timeliness in line with legislation and statutory guidance;
• providing a resource to enable those involved in reviews to answer common questions;
• clarifying local roles and responsibilities including the decision making and publication responsibilities of the SAB;
• providing transparency about the review process;
• supporting practical planning and preparation of reviews.

1.2 Legislation and Statutory Guidance

Section 44 of The Care Act 2014 outlines the SAB’s core duty to conduct SARs.

Chapter 7, Safeguarding in the Care and Support Statutory Guidance contains guidance on conducting safeguarding adult reviews.

2. Purpose of a SAR

The Care and Support Statutory Guidance states that the purpose of a SAR is to:

‘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. 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. Its purpose is not to hold any individual or organisation to account’.

SARs are not disciplinary proceedings, and should be conducted in a manner, which facilitates learning, and appropriate arrangements must be made to support staff. SARs are not enquiries into why an adult has died (or has been significantly injured), or who is culpable. These are matters for criminal courts and Coroner’s courts.

3. Safeguarding Principles

The Care Act 2014 states SARs should reflect the six safeguarding principles:

• Empowerment – People being supported and encouraged to make their own decisions and informed consent
• Prevention – It is better to take action before harm occurs
• Proportionality – The least intrusive response appropriate to the risk presented
• Protection – Support and representation for those in greatest need
• Partnership – Local solutions through services working with their Communities have a part to play in preventing, detecting and reporting neglect and abuse
• Accountability – Accountability and transparency in delivering safeguarding.

For more information on the safeguarding principles, see Safeguarding: What is it, and why does it Matter?

In the context of these principles the SAB will conduct SARs in a way that ensures:

• leadership by individuals who are independent of the case under review and of the organisation whose actions are being reviewed.
• a culture of continuous learning and improvement, promoting the wellbeing and empowerment of adults, promoting good practice and focusing on opportunities to apply what works.
• a culture of transparency is created that identifies a flexible and proportionate environment for learning.
• a proportionate response that identifies timely action is taken to respond to the need for systematic or professional changes.
• involvement of professionals to contribute their perspective without fear of being blamed for actions they took in good faith.
• families are invited to contribute to the reviews, understanding how they are going to be involved.
• contribution to processes that explore the broad issues and learning in a wider multi-agency setting rather than limiting the potential to develop solutions to those agencies involved in the case.

4. SAR Criteria

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

• there is reasonable cause for concern about how effectively the SAB, members of it or other persons with relevant functions, worked together to protect the adult, and either;
• the adult has died, and 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); or
• the adult is still alive, and the SAB knows or suspects that the adult has experienced serious abuse or neglect.

If the circumstances of a serious incident meet the criteria as detailed above, this is a statutory review.  However, the SAB can also arrange for a SAR to be undertaken in any other situations involving an adult in its area with needs for care and support, if it has been deemed that there would be important learning for the multi-agency partnership.  This would be a discretionary review.

Methods which can be considered for a review include:

• Action Learning Approach;
• Peer Review Approach;
• Thematic Reviews;
• Single Agency Review;
• Practitioners Learning Events Meeting;
• Quality assurance / multi agency audit;
• Desktop review;
• SAR in rapid time;
• Traditional SAR.

See Appendix 1 – Bury SAB Decision Flowchart for reviews under the Care Act 2014 and local prompt questions

5. Making a Referral for a SAR

The SAB is the only body that can undertake a SAR. The purpose of having a SAR is not to reinvestigate or to apportion blame, it is to establish whether there are any lessons to be learnt from the circumstances of the case, about the way in which local professionals and agencies work together to safeguard adults

Any agency, professional or other individual can make a referral for a SAR if they believe the case meets the criteria for consideration. A referral must be made using the Safeguarding Adult Review Referral Form. Professionals will usually find it helpful to discuss their concerns with their agency’s safeguarding lead prior to making a referral. The SAR referral should be made as soon as it is recognised the SAR criteria could be met. A referral can be made at any stage of a Safeguarding Enquiry, even if the enquiry remains ongoing. This referral does not replace Safeguarding Adult Enquiries, which would look at immediate safeguarding and protection for adults at risk.

See Appendix 2 for the BSAB SAR Referral Form. Referral Forms should be emailed to [email protected]

6. Decision

6.1 Decision Process

Once a referral is received, the Business Unit will send an email to the referrer confirming receipt. The Business Unit will also notify the Independent Chair that a referral has been received.

The Business Unit will circulate the SAR referral and convene a screening panel meeting of the three statutory partner representatives (Bury Council, NHS Greater Manchester integrated Care Board and Greater Manchester Police) to consider whether the criteria are met.

Having considered the SAR referral and the relevant agency information, the screening panel will be responsible for making a recommendation to the SAB Independent Chair about whether to commission a SAR or not. Screening panel members will also consider whether a discretionary SAR will be undertaken if there is the potential for multi-agency learning, and this is part of the screening panel documentation (Appendix 3a – Bury SAB Case Screening Decision Document).

If the SAR referral does not include adequate information to make an informed decision on whether the criteria for a SAR is met, the screening panel members will request additional information from relevant agencies to support their decision making. This will not be a full scoping request (which will is only used when a SAR is being undertaken); however, it will be a request for summary information from relevant agencies (see Appendix 3b – Summary information request template).

It will be the responsibility of each agency representative attending a SAR screening meeting to feedback the outcome of the screening and any identified learning within their agency, particularly when cases involve an adult that agencies are currently working with.

If the screening panel conclude that a SAR should be undertaken, then consideration will be given to draft Terms of Reference, the methodology to be used, the scoping period, and the membership of the Review Panel. If the screening panel conclude that a SAR should not be undertaken, then consideration will be given to other types of reviews that could be carried out, and whether the SAB should retain oversight of these. If the screening panel conclude that additional information is required before making a recommendation, then the Business Unit will coordinate the actions as agreed by the screening panel, and collate and then share all additional information with the screening panel. A further screening panel will be scheduled in order to reach a recommendation.

The SAR Decision Document (Appendix 3a – Bury SAB Case Screening Decision Document) will be completed by the Business Unit in conjunction with the screening panel members. The SAB Independent Chair will notify the Business Unit of their decision using this document. If the SAB Independent Chair disagrees with the recommendation, a further meeting of the screening panel may be arranged to discuss a response to the SAB Independent Chair.

The Business Unit will share the SAB Independent Chair’s decision with the referrer. If the referrer wishes to appeal against a decision not to carry out a SAR, the appeal should be put in writing to the SAB Independent Chair, who will, if necessary, discuss and review the decision with the referrer and the screening panel members who made the initial recommendation.

6.2 Decision Process Timeframe

Action	Timeframe	Approximate Working Day(s)
Referral received.	As soon as is reasonable after case has been identified.	0
Screening panel members and Independent Chair notified.	Within 2 working days of the referral being received.	2
Screening panel meeting arranged and invitations issued.
Screening panel members review relevant background information and contact other agencies for any additional information where appropriate	Within 3 working days of request being sent, or prior to the screening meeting taking place	3
Referral screened by screening panel members (three statutory partner representatives)	Usually within 10 working days of the Referral being received.	10
Screening panel recommendation sent to Independent Chair.	Within 1 working day of the screening panel meeting	11
Independent Chair decision received.	Within 2 working days of the screening panel meeting	13
Decision shared with the referrer	Within 2 working days of the decision from the Independent Chair	15

7. SAR Procedures

7.1 Good practice

The Care and Support Statutory Guidance states that :

the SAB should aim for completion of a SAR within a reasonable period of time and in any event within six months of initiating it, unless there are good reasons for a longer period being required; for example, because of potential prejudice to related court proceedings’.

A SAR will be conducted in a way which:

• recognises the complex circumstances in which professionals work together to safeguard adults;
• seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;
• seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;
• seeks to determine what relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death;
• encourages honesty and transparency;
• facilitates learning;
• makes use of relevant research, case evidence and previous SARs in Bury to inform the findings.

7.2 SAR Process

The SAB will aim to complete a SAR within six months of the decision for it to be undertaken. The approach for a SAR will be proportionate to the specific circumstances of the case. For example, a SAR in Rapid Time model may be more proportionate and timely than a traditional SAR.

The Business Unit will inform the Coroner and the statutory SAB members of the intention to undertake a SAR. The Business Unit will also notify the individual and/or their family, advocate as appropriate (see Appendix 4 – Information for Family, Friends and Care Givers).

The screening panel members will consider the format of the SAR as part of the screening panel meeting.

If required, the Business Unit will commission an external Independent Author for the SAR (see Section 9: Appointment and Role of the Independent Author) as required. The Referral and SAR Decision Document will be shared with the Independent Author.

An initial Panel Meeting will be held to finalise the Terms of Reference, the methodology to be used and the scoping period. It will also be determined which types of report/summaries partner agencies will requested to provide. The Agency Report/Summary template will be approved by the Independent Author before being distributed.

The Terms of Reference may, however, need to be revisited as the review progresses and as new information is identified. SAR Review Panel members will make a recommendation to the Independent Chair to approve amendments to the Terms of Reference.

The Business Unit will ask representatives of SAB partner agencies to complete an Agency Report/Summary and chronology. Agency Reports/Summaries and chronologies should be completed by managers who have not had operational responsibility for the case but who understand the service. Agency representatives will inform the Business Unit if a briefing session, offering guidance to complete the Agency Report/Summary, is required. Once all Agency Reports/Summaries are received, the Business Unit will combine chronologies into a single file and share this with the Independent Author and the members of the Review Panel.

The Independent Author will progress work to extract the learning. This part of the process will be facilitated by the Business Unit and will be dependent on the methodology chosen.

SARs can be conducted in a variety of ways. Traditional methods involve analysis of the involvement of agencies, led by an independent overview report author. With this method, individual agencies are asked to review the practice within their organisation through Individual Management Reviews (IMRs) and Chronologies, which then form part of an Overview Report.

Other methods considered for a review:

• Action Learning Approach;
• Peer Review Approach;
• Thematic Reviews;
• SAR in rapid time;
• Practitioners Learning Events Meeting;
• Quality assurance / multi agency audit;
• Desktop review.

The review period will include the opportunity for the individual or their families to meet with the Independent Author.

A first draft of the Overview Report will be written by the Independent Author and shared with the Review Panel members for their feedback.

Review Panel members will discuss the issue of using the real name of the individual or a pseudonym in the Overview Report. Whilst the views of the individual and/or their family members will be taken into account, ultimately this is for the SAB to decide.

The final Panel meeting will include discussion about any communication issues and decisions made about what information needs to be communicated and to who (see Section 17, Media and Communications Strategy).

Amendments and subsequent drafts of the Overview Report will be shared with the Review Panel members before the final version presented to the SAB for reflection on the review process, quality assurance and sign off as well as discussion concerning publication.

It will be the responsibility of the Adult Case Review Subgroup to identify and agree how practice challenges or recommendations from the Overview Report will be responded to and what action is needed by individual agencies or from a multi- agency perspective.

8. Information Sharing and Retention

Section 44 of the Care Act 2014 states that:

‘each member of the SAB must co-operate in and contribute to the carrying out of a review with a view to identifying the lessons to be learnt from the case and applying those lessons to future cases’.

Section 45 of the Care Act 2014 outlines compliance in relation to supply of information.

Information received for the purpose of SARs must not be stored for longer than necessary, and must not be used or shared in any way without the prior consent of the SAB members. SAB partner agencies and their representatives should be aware, as public bodies, that the information provided to the SAB can then be requested by the Crown Prosecution Service or by HM Coroner as part of ongoing investigations. Therefore, senior management oversight should be sought prior to information being submitted. Should a request for information be made by the Crown Prosecution Service or by HM Coroner, then the relevant partner agencies will be notified by the SAB Business Unit.

9. Appointment and Role of the Independent Author

9.1 Required skills and expertise

An Independent Author can be sourced from the membership of the Safeguarding Adults Board, internally within partner agencies, or through an external commission.

The Independent Author should be an experienced individual who is not directly associated with any of the agencies involved in the SAR. Consideration should be given to the skills and expertise required to effectively lead a SAR including:

• Strong leadership and ability to motivate others;
• Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
• Collaborative problem-solving experience and knowledge of participative approaches;
• Ability to find and evaluate best practice;
• Good analytical skills and ability to manage quantitative and qualitative data;
• Knowledge of safeguarding adults and an understanding of the complexity of the health and social care system;
• Ability to write for a wide audience.

9.2 Responsibilities

The Independent Author will be responsible for chairing Panel meetings, effectively leading and coordinating the Review Panel and for quality assurance of the final Overview Report based on the Agency Reports/Summaries and any further evidence deemed relevant.

The Independent Author will be responsible for the final decision on the suitability of the Terms of Reference, agreed with the Review Panel members at the initial Panel meeting. The Terms of Reference may, however, need to be revisited as the review progresses and as new information is identified; the Independent Author will agree any amendments with the Review Panel members.

The Independent Author will establish an agreed timetable of key dates for the review to include, for example, Panel meetings and learning events.

The Independent Author will be responsible for engagement with the individual and/or their family. This will be facilitated by the SAB Business Unit. The Independent Author will direct any media interest about the SAR to the SAB Business Unit who will respond following consultation with Bury Council Communication team. The Independent Author will ensure that regular updates are obtained regarding agencies providing services to meet the safeguarding or other needs of individuals who are subject of the SAR. The Independent Author will maintain contact with the lead personnel of all parallel reviews or investigation processes, to ensure that any coordination and joint commissioning arrangements are effective (see Section 12, Parallel Processes).

The Independent Author will produce a final Overview Report, ensuring that the review is of a sufficiently high standard and that wherever possible, multi-agency recommendations are succinct. The Independent Author will, as far as possible, ensure that the review process is a learning exercise in itself for all those involved in the case.

The Independent Author may be required to attend the Coroners Court as a witness, to present their report.

The Independent Author will take into account similar thematics from previous BSAB SARs, as part of their Overview Report.

The responsibilities will be set out in the appointment letter to the Independent Author (See Appendix 7: Commissioning Letter to Independent Author).

10. Involvement of Individuals, Family Members, Friends and other Support Networks

The Care and Support Statutory Guidance highlights that adults, their families and/or representatives should be invited and supported to contribute to SARs.

Individuals who are the subject of a SAR and/or their family members can offer a unique perspective into how the delivery of services and involvement of agencies were viewed. It is essential that the Independent Author and Review Panel have opportunities to hear their experiences and perspectives, and that these contribute meaningfully to the final Overview Report. Family members can include carers and any significant family members identified from the Genogram.

Engagement of the individual at the centre of the review and/or their family members will be discussed initially by the Adult Case Review Group and facilitated by the Case Review Officer. The individual and/or their family members will be notified of the intention to complete a SAR. Information will be provided outlining what a SAR is (See Appendix 4 – Information for Family, Friends and Care Givers), and an opportunity will be offered to give the individual and/or family members time to discuss the process in more detail with the Independent Author. The individual and/or their family members will also have the opportunity to contribute to the terms of reference should they choose to.

The Independent Author, via the SAB Business Unit, will be the main point of contact for the individual and/or their family throughout the review. The SAB Business Manager will arrange an independent advocate should this be required.  Where such services exist, consideration should be given to signposting the individual and/or their family members to support services independent of the review.

Local authorities must arrange an independent advocate for adults who are subject to a SAR if the following two conditions are met:

• that if an independent advocate were not provided, the person would have substantial difficulty in being fully involved in the process; and
• there is no appropriate individual available to support and represent the person’s wishes who is not paid or professionally engaged in providing care or treatment to the person or their carer.

It is for the local authority to form a judgement on a case by case basis about whether the adult has ‘substantial difficulty’ in being involved in the SAR process.

The role of the independent advocate is to support and represent the person and to facilitate their involvement in the key processes and interactions with the local authority and other organisations as required for the SAR, to help them to understand and take part in the review and to express their views wishes or feelings.

As a minimum, individuals and/or their family members will:

• Be notified of the review process, what that means for them and how they can access support, including impact of media coverage.
• Agree the level and frequency of contact to ensure they are kept informed.
• Be supported to contribute to the review process, either in writing, by meeting with the Independent Author, sharing views via a third party or by other means identified by the Review Panel.
• Be informed of the publication of the report in a timely manner, including the likelihood of media interest.
• Be provided with a read-only, pdf, copy of the report which family members can review and comment on prior to publication but not retain; where possible any relevant comments should be incorporated into the final version. A ‘hard’ copy of the report should not be provided until the report is in the public domain.
• Be given an opportunity to provide feedback to the BSAB on the SAR process and their engagement.

11. Agency Representatives on Review Panel

The agencies that will be represented on the Review Panel will be agreed by the screening panel. Agencies will have been involved in the case, but the representative themselves will not be directly involved in the case. Representatives will have sufficient knowledge of the agency and practice within it.

Representatives will:

• attend and contribute to panel meetings (or learning events/audits depending on methodology used);
• be consistent, deputies will be permitted in exceptional circumstances;
• contribute agency information and/or specialist knowledge to the review;
• consistently feedback any learning within their agency, as it is determined throughout the process, particularly when reviews involve a subject that agencies are currently working with;
• support the development of a positive learning environment across the SAB and support the Independent Author to extract learning from the review;
• analyse information provided and support the Independent Author to develop review recommendations;
• have an awareness of the Legislation and Statutory Guidance in relation to SARs and ensure that appropriate learning is developed whilst adhering to review timelines;
• quality assure drafts of the Overview Report, ensuring that the review is of a sufficiently high standard and sufficiently anonymised in preparation for publication.

12. Parallel Processes

12.1 Principles

The Independent Author and Review Panel members will consider how the SAR process is linked with other relevant investigations, such as Mental Health Homicide Reviews, Child Safeguarding Practice Reviews or Rapid Reviews, Domestic Homicide Reviews or Learning Disability Mortality Reviews (LeDeR), how duplication can be avoided and how these can potentially dovetail at the beginning of the process. Consideration of other relevant investigations should inform the development of the Terms of Reference. The Independent Author will maintain contact with the lead personnel of all parallel reviews or investigation processes, and to ensure that any coordination and joint commissioning arrangements are effective.

12.2 Joint Borough safeguarding adult reviews

Safeguarding Adult Reviews held jointly with other Boroughs will adopt the learning and improvement framework of the Borough hosting the review. If a Safeguarding Adult Review is being considered, the Safeguarding Adults Board of the host authority will be responsible for liaising with all partner agencies involved.  The SAB in those areas would be contacted to be advised of the SAR but not expected to collate the information on behalf of the hosting SAB (See Appendix 6: Greater Manchester Cross Boundary Flowchart). It is recognised that some agencies operate across a number of SABs across Greater Manchester, and they would be required to work with the SAB of the host authority as their single point of contact to minimise duplication for that agency.

As stated in the Care Act, Section 44, Boards and organisations should co-operate across borders and requests for the provision of information should be responded to as a priority.

Learning for the SAB from these reviews will be facilitated by the SAB Learning and Development Subgroup.

12.3 Out of Borough issues in relation to responsibility for a SAR

Where there are cross boundaries and/or cross boundary commissioned support, or no commissioned support in place, a sensible and proportionate approach is needed, and the lead SAB should be where the adult is best known and the potential learning would be applied. (See Appendix 6: Greater Manchester Cross Boundary Flowchart).

The relevant Board Managers and Independent Chairs should agree how the SAR will be undertaken.

If agreement cannot be reached on the requirement for a SAR to be undertaken then this will be resolved in the first instance by the relevant Board Managers, with ultimate decision making and discussion being resolved by the Independent Chair of the Safeguarding Adult Boards.

12.4 Concurrent police investigations or judicial proceedings

The SAR will need to take criminal investigations and Coroners Inquiries into account to ensure that relevant information can be shared without significant delays to the review process.

Where a concurrent ongoing criminal investigation is identified, the Review Panel will make contact with the Senior Investigating Officer, early in the process and then regularly, via the police representative on the Review Panel, to ensure no conflict exists between the two processes. This relates particularly to any planned interviews with family members, practitioners and managers and must take into account that any one of these people may be potential witnesses or defendants in a future criminal trial.

12.5 HM Coroner

deaths or deaths of unknown cause, and deaths in custody, or otherwise in state detention, which are reported to them. The Coroner may have specific questions arising from the death of an adult at risk. These questions will usually be related to a case:

• where there is an obvious and serious failing by one or more agency;
• where there are no obvious failings, but the actions taken by agencies require further exploration/explanation;
• where a death has occurred and there are concerns for others in the same household or other setting (such as a care home);
• where the Coroner identifies deaths that fall outside the requirement to hold an inquest but follow up enquiries or actions.

In the above situations, the SAB should consider instigating a SAR.

HM Coroner may want to be in receipt of the final Overview Report. The SAB Business Unit will work in conjunction with the Council’s Legal Services and SAB Independent Chair regarding communication with the Coroner’s office on behalf of the SAB.

There are procedures in place for the Coroner to request information from the SAB or individual partner agencies regarding coronial matters. If a request comes in from the Coroner to individual agencies for SAB business, then the Coroner should be redirected to the business unit of the SAB and vice versa. See Notification and Information Sharing between HM Coroner’s Office and Bury Safeguarding Adults Board

13. Practitioner Learning Events

Depending on the methodology of the review, the Independent Author and Review Panel will determine if a Practitioner Learning Event would support the review process and provide additional multi-agency learning. If a Practitioner Learning Event is to be held this will be organised by the Case Review Officer. It is an expectation that the Independent Author, members of the Review Panel (this must include statutory agencies), managers who collated the Agency Reports/Summaries and key practitioners identified from agencies will attend this event. The event will be quorate if the Independent Author considers there is appropriate representation to conclude adequate learning without having to duplicate a further meeting.

The Practitioner Learning Event will seek to:

• be trusted and safe experiences for practitioners and encourage honesty and transparency.
• determine what agencies and individuals involved in the case might have done differently that could have prevented harm or death.
• identify lessons learned that can be applied to practice.
• share information between agencies to obtain maximum benefit.
• identify recommendations for consideration by the Review Panel.
• provide practitioners with the perspective of the individual and/or their family members.

More than one meeting may be required to ensure the contribution of key practitioners to the learning process. It may be appropriate to host separate meetings for reflection and confirmation of the learning points.

14. Resolving Disagreements

Where disagreements occur, they are to be resolved, wherever possible, through the chosen methodology (i.e. Practitioner Learning Event and/or traditional review model with Panel meetings). However, in order for the Independent Author to maintain independence, any disagreements which cannot be resolved will be escalated to the Independent Chair of the SAB for resolution where possible and will be noted in the Overview Report by the Independent Author.

If there is concern from Panel Members that the SAR is moving away from the principles of the SAR framework and learning from the case, this should be raised at Board level with the Independent Chair, who will make a decision on how to proceed, in consultation with the three statutory partners.

The SAB are responsible for making the final decision on whether to accept the report of the Independent Author in its entirety, and will consider any areas of disagreement which may remain unresolved.

15. The Final Overview Report

The Overview Report brings together the learning, themes identified from the review and analyses and comments on the effectiveness of practice, and the systems used to safeguard and promote the welfare of the adult and what actions need to be taken to prevent an occurrence happening in the future. The Overview report will also contain findings and recommendations of practical value to agencies and professionals. The Overview Report will be anonymised and written concisely, in plain English.

16. Presentation of Overview Report and Executive Summary to SAB

16.1 Presentation process

The Independent Author will present the Overview Report to the SAB, supported by the Chair of the Adult Case Review Subgroup. It may be necessary to arrange an Extraordinary Meeting of the SAB for this purpose. The report will be available at least five working days prior to the SAB Meeting.

16.2 SAB Responsibilities

Through the presentation of the Overview Report, the Independent Author and Review Panel will make their recommendations to the SAB concerning the use of the real name of the individual or a pseudonym. Ultimately, the SAB will make the final decision. Similarly, the Independent Author and Review Panel will make recommendations to the SAB in relation to information that should be anonymised or redacted within the Overview Report, such as the name of a Care Home or GP practice. Ultimately, the SAB will formally agree the format of what is to be published.

Primarily, the SAB will be concerned with what needs to be learnt, where agencies and practice require improvement and how any programme of action will lead to sustainable improvements. The SAB may identify additional learning to inform strategic direction for individual agencies.

The Overview Report will be signed off by the SAB.

16.3 Publication responsibilities

It will be the responsibility of the SAB to determine publication of the review. There is no requirement for the SAB to publish a SAR that it has commissioned. However, the Care and Support Statutory Guidance does identify that, ‘In the interest of transparency and disseminating learning the SAB should consider publishing the reports within the legal parameters about confidentiality’. As such, whether publication is approved, will be determined on a case-by-case basis and consideration will need to be given to the specific details of each SAR.

Before the Overview Report can be published the SAB will make formal decisions based on the following:

• Is the report accurate in terms of content?
• Is the report thorough in terms of analysis?
• Should this report be published? It is not acceptable to publish a 7- minute briefing only.
• Does approval for publication need to be agreed subject to further consultation with the family?

If the BASB agree to publication of the report, this will be published on the BSAB website and a copy will be shared with the National SAR Library.

17. Media and Communications Strategy

17.1 Agency involvement

Issues related to media and communication issues will usually be coordinated by the Business unit with the Bury Council Communications team.

17.2 Publication process

In preparation for the publication of a SAR, the SAB Business Unit will:

• agree a date for publication;
• ensure the Review Panel have received the final version of the Overview Report;
• liaise with the Council Communications team about potential for press interest;
• inform individual and/or family members by letter;
• inform Independent Author;
• inform SAB members of the intention to publish the Overview Report;
• inform the lead member and Chief Executive and consider if an elected members brief is required;
• liaise with Panel members so that their Communications teams can be alerted (Review Panel members to provide communication lead from their respective agency to the SAB Business Unit);
• circulate the final version of the Overview Report to Communication leads, as required;
• ask partner agencies to have their own statements ready (liaison should take place with Council Communications team about jointly prepared statements).

The SAR will be published on the BSAB website and sent to the National Network for Chairs of Adult Safeguarding Reviews who maintain a national library of SARs.

If partners have media queries, they must liaise with the Council Communications team before making a response so that the level of exposure and risk can be assessed.

17.3 Media and communications strategy in preparation for an inquest

The SAB Business Unit will liaise with Bury Council Communications team regarding a statement to be made by the SAB Independent Chair on behalf of the SAB. The statement will be prepared in advance of an Inquest. The statement will be made available to partner agencies through Review Panel members and can be used to assist agencies with responses to media enquiries where appropriate.

18. Action Plans

18.1 Developing action plans

Following Board approval of the Overview Report, a clear Action Plan will be developed by the Review panel with a focus on improving outcomes for adults at risk. Actions will be Specific Measurable Achievable Realistic and Time bound (SMART) and clear action owners will be assigned.

18.2 Scrutiny Panel Process – monitoring of action plans

Findings and lessons from SARs are set out in the recommendations within each SAR report and these recommendations form the basis of multi-agency and single agency actions plans. The Case Review Subgroup is responsible for overseeing the delivery of these actions which are delegated to individual agencies and relevant SAB Subgroups to ensure learning is translated into multi-agency policies and procedures, embedded through workforce development initiatives and reviewed through service user feedback and the quality assurance systems.

The Adult Case Review Group will hold Scrutiny Panel meetings to review progress of action plans. Action owners will be asked to attend to provide evidence to demonstrate how actions have been implemented and discharged, and what difference these have made. Where possible, Scrutiny Panel sessions will take place during scheduled Adult Case Review Subgroup meetings to minimise the additional demand on Adult Case Review Subgroup members.

Where actions are delegated to a SAB Subgroup, a representative from the Subgroup will be asked to attend the Scrutiny Panel session and deadlines will be set to allow there to be sufficient time to meet and develop responses. Where there are no plans to address outstanding actions, or agreement cannot be achieved at the Scrutiny Panel session in the first instance, the actions will be escalated to the SAB for resolution of ownership and onward accountability.

19. Complaints and Escalation Procedure

The SAB Business Manager will initially respond when a complaint about a SAR is received, with a written response within 28 days of receipt.

If the complainant is dissatisfied with the response, they should contact the SAB Business Manager who will arrange for their complaint to be considered by the SAB Independent Chair. The SAB Independent Chair will provide a further written response within 28 days of the complainant.

All written complaint responses will include details of how to contact the Local Government Ombudsman. The SAB Business Manager will ensure that a record is kept of complaints received, responded to and those referred to partner agencies. Complaints and copies of responses will be securely retained in accordance with the principles of data protection legislation.

If there is a request in advance of a Scrutiny Panel session to extend the deadline for the action, this will be considered by the Chair of the Adults Case Review Subgroup, who may discuss with the Independent Chair of the BSAB (see Appendix 5 -Scrutiny Panel Flowchart).

20. SARs and the SAB Annual Report

The Care Act 2014, Schedule 2, mandates that the findings from all completed and ongoing SARs will be reported in the SAB Annual Report alongside actions taken, or actions the SAB intends to take, in relation to those findings and where it decides during that year not to implement a finding of a SAR, the reasons for its decision.

Appendices

Appendix 1 – Bury SAB Decision Flowchart for reviews under the Care Act 2014 and local prompt questions

Appendix 2 – Bury SAB SAR Referral Form

Appendix 3a – Bury SAB Case Screening Decision Document

Appendix 3b – Summary information request template

Appendix 4 – Information for Family, Friends and Care Givers

Appendix 5 -Scrutiny Panel Flowchart

Appendix 6: Greater Manchester Cross Boundary Flowchart

Appendix 7: Commissioning Letter to Independent Author