1. Elder Abuse Conference 7th December 2011Serious Case Reviews Workshop Mick Collins Senior Manager Social Services Powys County Council Chair PAVA Wales

2. Contents of Presentation • The purpose of SCRs • The process of SCRs • Research and Issues from SCRs • SCRs or Practice Reviews ?

3. The Purpose of SCRs (1) • Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard vulnerable adults; • Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; • Improve inter-agency working, and better protection and support of vulnerable adults. • Source: Wales Guidance for Conduction Inter-Agency Adult Protection Serious Case Reviews

4. The Purpose of SCRs (2) SCRs focus upon case management, especially by health and social services, and not necessary on adult protection procedures. Many SCR cases were not referred for specialist adult protection. Note: Safeguarding is everyone’s business but adult protection requires specialist training of Designated Lead Managers and Investigators

5. No SCR required and other options considered The Process for SCRs SCR request received by APC Chair Request passed to SCR Sub-Group and agreed Sub-Group ensures that SCR will be co-ordinated with any other processes e.g. criminal prosecution Terms of Reference drafted for Panel, Independent Chair appointed and Panel convened Management Reviews requested from all involved agencies Independent Reviewer appointed by Panel Panel and Reviewer receive Management Reviews Reviewer considers Management Reviews, undertakes other work as necessary and submits Overview Report to Panel Panel submits final report to APC APC receives SCR and drafts Action Plan for implementation and review

6. Research Data: Manthorpe and Martinean (22 Cases) Serious Case Reviews in Audlt Safeguarding in England: An Analysis of a Sample of Reports Jill Manthorpe and Stephen Martinean BJSW (2011) 41 224-241

7. (Selected) Issues from the Research • Deficits in interagency communication • Lack of clarity as to lead agency • Failure to assess properly the risk to vulnerable adults • Lack of awareness about adult protection procedures • Lack of whistleblowing policies or awareness thereof • Lack of advocacy and • Lack of standardisation of SCR themselves including lack of clarity regarding thresholds: seriousness of outcomes and / or possible systems failure.

8. Issues from SCRs High profile English examples • Steven Hoskins • Michael Gilbert • Francecca Hardwick / Fiona Pilkington Examples from Wales • Multiple victims : sexually abused elderly women and men • Adult A : suspected neglect of elderly man • Multiple victims : neglect / deaths elderly men and women • Adult B : neglect / death of woman with special needs

9. SCRs or Practice Reviews? (1) Professor Munroe “This review recommends regular review of cases becomes the norm and that the ‘systems approach’ used in the health sector is adopted and applied, in particular, to Serious Case Reviews. This will enable deeper learning to overcome obstacles to good practice.

10. SCRs or Practice Reviews? (2) The Government should work with LSCBs to develop national resources to: • provide accredited, skilled and independent reviewers to jointly work with LSCBs on each SCR; • promote the development of a variety of systems-based methodologies to learn from practice; • initiate the development of a typology of the problems that contribute to adverse outcomes to facilitate national learning; and • disseminate learning nationally to improve practice and inform the of the Chief Social Worker.

11. Helpful further information on SCRs • Journal of Adult Protection Vol 13 Number 4 2011 Critical decisions and questions regarding SCRs – ideas from North West England Margaret Flynn, Kirstey Keywood and Shirley Williams • Social Care Institute for Excellence Papers: At A Glance September 2009 Learning together to safeguard children: a ‘systems’ model for case reviews November 2010 Piloting the SCIE ‘systems’ model for case reviews: Learning from the North West of England.