Critical decisions and questions regarding serious case reviews – ideas from North West England

1 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Critical Decisions and Questions Regarding

Serious Case Reviews – Ideas from the North

West: Briefing Paper 31

Margaret Flynn, Kirsty Keywood, and Shirley Williams

Introduction

In financially lean times when public attention is focused on “cuts”, frozen budgets,

job losses and discontinuity of personnel in the public sector, it is essential that adult

safeguarding re-visits all activities and asks whether or not there are other ways of

doing things. One area of activity that can be expensive in staff time and in payment

to individuals, who are contracted to provide a degree of independence to an inquiry,

is the serious case review (SCR) process. This paper draws on the experience of

chairing and writing SCRs relating to adults and discussing these with other chairs

and authors, health, police and social care managers and practitioners. The ideas

expressed in this Briefing Paper build on those of Hilary Brown2 (2009) explored in

her depiction of SCRs that took place in the Kent and Medway region, where she

chairs the standing SCR Panel for the Safeguarding Adults Board, with additional

reflections from SCRs that she has chaired /authored in other areas. The knowledge

base of Serious Case Reviews involving adults is developing,3 but is still at the level

1 This paper has been produced as part of the NW Joint Improvement Partnership Project on Safeguarding Adults, which concluded at the end of March 2011.This and other papers can be downloaded from www.northwestjip.co.uk until March 2012. 2 Brown, H, “Brown H“, The Process and Function of Serious Case Review” (1999) 11(1) Journal of Adult Protection 38-50. 3 See, Manthorpe J and Martineau S, (2011) “Serious Case Reviews in Adult Safeguarding in England: An Analysis of a Sample of Reports” The British Journal of Social Work, 41(2), 224-241; Manthorpe, J. and Martineau, S. (2009) Serious Case Reviews in Adult Safeguarding Social Care Workforce Research Unit, King’s College London

2 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

of description rather than providing Boards and safeguarding practitioners with well

tested and evidence-informed support for their decision making.

What is a Serious Case Review (SCR)?

All organisations wishing to learn have a process by which they reflect on things that

have gone wrong in order to identify what exactly went wrong, who contributed to it

going wrong, why it went wrong, and what can be done to prevent the same thing

happening again. A SCR is such a process and in health and social care services

may be described as a case study. Typically, a case study is a concentrated, pan-

disciplinary inquiry into individual cases, which offer opportunities for learning.4 The

method of inquiry used is a secondary consideration, though process can affect

outcome and as we have seen in children’s services, an overly prescriptive, Ofsted-

evaluated process has attracted increasing criticism.5 Case studies draw attention to

the question of what may be learned from events concerning an individual or may

look at a group of people in a residential home, for example. Such cases are

examined to provide insight and facilitate understanding of particular circumstances

by distinguishing between what is particular and what is uncommon about a case.6

A SCR, as with an Individual Management Review (IMR), a service quality

improvement review and a serious untoward incident investigation, has the potential

to make long term improvements to working across professional groups as well as

agencies, but a great deal hinges on a full understanding of the contexts within which

professionals make decisions. SCRs operate within physical, economic, ethical,

legal, policy and political contexts and, as with all case studies, a SCR calls for the

examination of the interplay of systems as well as the behaviour of individuals, in

order to ascertain the “root cause” of an adverse outcome.7

4 Stake, R.E. (2000) Case Studies, in N.K. Denzin and Y.S. Lincoln (Eds.) Handbook of Qualitative Research, Second Edition, London, Sage Publications, Inc. 5 See The Munro Report on Child Protection: A Child Centred System Final Report, 2011. Cm 8062. 6 Unlike in children’s safeguarding there is no statutory requirement to undertake a SCR of an adult, though it is regarded as good practice and ADASS has issued guidance on when to carry out an SCR and how to conduct it. See: ADASS (2010) Vulnerable Adult Serious Case Review Guidance- Developing a local protocol.

7 See www.nrls.npsa.uk

3 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Why are SCRs important?

The publication of Executive Summaries of adult SCRs can be powerful jolts partly

because there are many fewer adult SCRs than there are children’s SCRs. Typically

they draw their urgency from the deaths of vulnerable adults or the serious

abuse/neglect of a number of adults in a grouped care setting. Many families also

state that they want an inquiry as they want agencies to learn and don’t want others

to experience abuse and neglect as their relative may have done. Whilst there is

sometimes confusion among families about the process being a way of identifying

who is to blame, this desire for professionals to learn is genuine and is often

expressed as “something good needs to come from this tragedy”.

In the North West, there is refreshing and growing caution about undertaking more

adult SCRs because an increase in volume may result in a potential loss of their

impact. Also, there is concern that the often false and superficial appraisal of

children’s SCRs - “They all say the same thing” - may transfer to adult SCRs. There

is also concern that adult safeguarding processes are in danger of becoming

tethered to a template of how to conduct a SCR - which is derived from children’s

SCRs and, whilst seen as providing a degree of consistency, is in danger of

routinising the consideration of exceptional incidents .

The Chairs of Adult Safeguarding Boards in the North West are willing and interested

in considering other approaches to learning lessons about the ways in which

agencies have worked together to safeguard adults at risk. Learning is a complex

process and nationally, the Executive Summaries of adult SCRs are untested in

terms of how they are shared and used within and beyond the authority concerned.

Nationally, there is a poor track record of sharing the lessons from SCRs. It appears

that the more uneventful days that can be marked up in adult safeguarding, the more

naively confident Safeguarding Boards can become that everything must be OK.

Also, there is no shortage of relief that SCRs have been and are being

commissioned in other authorities - generally expressed as, “Thank heavens it didn’t

happen here!” This is not to imply a lack of readiness to scrutinise tragedies in the

North West, but rather an acknowledgement that the investment in learning from

salient incidents does not, and should not, hinge on a single method.

When the JIP Project was first being discussed in the North West there was a view

that one of the ‘deliverables’ should be a template for conducting a SCR. As the

Project progressed and discussions with colleagues endorsed the challenges to the

standard SCR process in children’s services, the authors believed that the best

contribution they could make was to set out some of the questions Safeguarding

Adults Boards should be asking i.e. to promote more thinking rather than write

guidance for more doing. This resulted in creating a series of “decision-points” and

questions to capture something of the challenges of commissioning, chairing, writing,

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and contributing to reviews of events that have resulted in harm to adults, who

should have been safeguarded. The questions are prompts to Safeguarding Adults

Boards to consider the appropriateness of undertaking a Serious Case Review.

While the influence of children’s SCRs is evident, the decision points encompass a

broadening of adult safeguarding horizons. Although it may appear that there is a

single way of commissioning and conducting SCRs, there is no single mode of

inquiry, type of practice and use of evidence that can claim to belong solely to adult

SCRs.

1. Commissioning a SCR

“We need a SCR!” “Do we?”

“We have carried out a Serious Untoward Incident (SUI)/ a Post Incident

Review (PIR) –why do we need to participate in a SCR?”

Not surprisingly most North West authorities are reviewing their SCR Policies but

there is concern that insufficient consideration is being given to the initial decision

making process as opposed to getting the detail of how the review is to be

conducted. There are different routes to determining whether a SCR is to be

commissioned. In the North West, some independent Chairs state that the final

decision is made by them alone and in others, the SCR sub-group and/ or the Chair

of the sub-group is instrumental. There have been examples in some localities

however, where the police take pre-emptive action and insist that a SCR is required.

Other Chairs adopt a “wait and see” approach and invite a single agency to draft an

Individual Management Review. Subsequently, this becomes the basis for the

decision whether or not to undertake a SCR.

There is a long tradition in health services of conducting case enquiries following

adverse incidents. The belated acknowledgement of Adult Safeguarding Boards in

the North West that the NHS has these parallel processes for learning lessons,

which are confidential to the NHS and not shared routinely with Boards, has

prompted some to re-badge their “SCR sub-group” as “SCR and Serious Untoward

Incident sub-group.” This makes explicit the expectation, now echoed at national

level,8 that NHS members of adult safeguarding boards need to address their adult

safeguarding concerns in NHS services in a transparent manner. The pending

8 Department of Health, (2010) Clinical governance, and adult safeguarding: an integrated process

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demise of Strategic Health Authorities and the National Patient Safety Agency add

urgency to the task of ensuring that safeguarding in the NHS is a matter of priority

and is communicated as such – going beyond the presence at adult safeguarding

personnel at board meetings. It is vitally important that NHS safeguarding leads

ensure that the implementation of, and adherence to, the adult safeguarding policy is

embedded within clinical governance frameworks and that safeguarding data is

presented for review and discussion at safeguarding board meetings. While there is

a case for ensuring that health matters are appropriately addressed in SCRs, there is

little merit in duplicating an investigation. If pan-disciplinary Safeguarding Adults

Boards are to realise their aims, they should be informed of the outcome of

enquiries, and the learning that has taken place. This should include reference

(anonymised) to any action against staff where misconduct has been proved and

which give rise to safeguarding concerns.

Agencies will want to conduct their internal reviews and this is right and proper if they

are to learn quickly from adverse incidents. Multi-agency consideration of serious

incidents is, however, particularly important where they involve people who are likely

to be more at risk than others through age or disability, and where there is some

expectation that they should have been protected. The information gleaned from

other forms of review can contribute to a multi-agency review, and duplication should

be avoided, but it is rarely sufficient in itself if learning is to take place across a whole

system.

It is important to note that there are contested rationales for undertaking a SCR.

These range from, a vulnerable adult has died so a SCR should be commissioned,

to adopting a process which permits agencies to inform the media that they are

taking action in the wake of a tragedy, and ultimately to acknowledge “It didn’t have

to be like this.” Even when there is a general consensus on the rationale for a

review, there may be considerable disagreement over how an investigation should

be framed and who should have overall responsibility for its direction. Some SCRs

might be re-allocated as Domestic Homicide Inquiries for example, or form the basis

of an Independent Inquiry into a homicide or suicide. Finally, there is interest in

determining a “SCR threshold” to bring consistency to the decision making but this

brings a danger of a ‘tick box’ approach driving the decision to proceed to a SCR,

rather than a local, professional, case specific dialogue. The debate over

professional decision making is receiving more attention in children’s safeguarding

through the inquiry by Eileen Munro.9

9 The Munro Report on Child Protection: A Child Centred System Final Report (2011). Cm 8062.

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So what do you do? Ask yourself…

What is the nature of the events or tragedies for which a SCR is the proposed

solution?

What outcomes are expected from undertaking the SCR?

Could these outcomes be legitimately achieved by a different process?

Does it appear that agencies, which should have worked together, did not do so?

Is a single agency setting aside the Safeguarding Adult Board’s policy and

insisting that a SCR is the only possible course of action?

Do the actions of the staff of a single agency suggest that (i) they have no

understanding of the purpose of adult safeguarding? (ii) they departed from

agreed adult safeguarding procedures? (iii) their actions were intended or

unintended?

Is the Safeguarding Adults Board familiar with the process which determines

whether or SUI or a PIR is undertaken?

How are NHS colleagues sharing the learning arising from relevant SUIs and

PIRs with Safeguarding Adults Boards?

Would an IMR by the agency with the most frequent association with the adult

who was harmed be a helpful start in identifying preliminary learning and tracking

of events?

Is there experience of undertaking joint reviews? If not, is there scope for doing

so?

Do (i) the Director of Adult Social Care,10, (ii) the local authority solicitor, (iii) the

Coroner, and (iv) the Care Quality Commission know that a SCR is being

considered?

2. Human Rights and the SCR

“Don’t we have to do an SCR to be Human Rights Act-compliant?”

10 Person occupying the DASS role.

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All actions by public authorities have to be compliant with the Human Rights Act

1998. An important question is whether the local authority is under a legal

obligation to conduct a SCR in respect of a vulnerable adult. The European

Convention on Human Rights protects the right to life (Article 2) and the right to

freedom from inhuman or degrading treatment (Article 3). These rights impose

obligations on public authorities such as local authorities, the NHS, police and

housing agencies to take appropriate operational measures to safeguard lives and to

guard against inhuman or degrading treatment. These so-called ‘positive’

obligations i.e. obligations to take positive steps to ensure that rights are enjoyed (as

opposed to ‘negative’ obligations to refrain from doing acts which result in the

deprivation of life or the subjection of inhuman or degrading treatment) are relatively

recent in their development by the courts. The House of Lords has recognised for

example, that health care professionals and hospitals providing support to patients

detained under the Mental Health Act 1983 owe an operational obligation to take

reasonable steps to prevent a real and immediate risk of death.11 In addition, the

European Court of Human Rights has confirmed that the failure of local authorities to

take appropriate steps to safeguard children from abuse and neglect can lead to a

breach of Article 312 and that a failure to provide effective legal mechanisms to hold

authorities and individuals to account for negligent conduct, which placed a

vulnerable adult at risk of death, amounted to a breach of the right to life.13 Events

which lead to the death, abuse or neglect of a vulnerable adult may therefore, in

certain circumstances, engage the liability of the state as a result of the inaction of

local authorities or other public agencies.

In circumstances where there may be liability on the part of the State for its failure to

safeguard life or wellbeing, there is an additional obligation on the State and public

authorities to conduct an effective investigation into the circumstances surrounding

a death or alleged abuse. Case law indicates that an investigation, or a series of

investigations, which is human rights-compliant, will have the following features. The

first two are particularly pertinent to criminal justice processes and the remainder are

of significance to adult SCRs:

It must be “capable of establishing the cause of the injuries and the

identification of those responsible with a view to their accountability and, if

appropriate, punishment”.14

The authorities must have taken “the reasonable steps available to them to secure the evidence concerning the incident, including eye witness testimony,

11 Savage v South Essex Partnership Trust [2008] UKHL 74. Note, however, that the Court of Appeal has refused to extend this same operational duty informally detained patients: Rabone v Pennine Care NHS Trust [2010] EWCA Civ 698. 12 Z v United Kingdom (2002) 34 EHRR 3. 13 Dodov v Bulgaria (2008) 47 EHRR 41. 14 Kelly and Others v UK Application no. 30054/96; Menson v UK Application no. 47916/99.

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forensic evidence and, where appropriate, an autopsy which provides a complete and accurate record of injury and an objective analysis of clinical findings, including the cause of death”.15

An investigation capable of “ascertaining the circumstances in which the incident took place and any shortcomings in the operation of the regulatory system”.16

A prompt investigation, permitting sufficient public scrutiny to secure accountability in practice as well as in theory.17

Involvement of family members and others in the investigative process who may claim to be ‘victims’ of the death/abuse.18

Independent of those whose conduct or inaction may be implicated in the event and not reliant on instigation by the victims.19

European human rights law does not insist on a specific forum in which these

matters should be investigated. Indeed, it may be appropriate for a number of

different bodies to hold investigations to address the totality of the requirements of

human rights law in this area (e.g. individual management review, complaint to

ombudsman, coroner’s inquest, police investigation, criminal and/or civil court

proceedings). Whatever processes are triggered, it is imperative that resulting

investigations meet these human rights and it is important for Safeguarding Adults

Boards to consider which of the Article 2 and 3 procedural requirements can

effectively be accommodate through the SCR process and which cannot. In most, if

not all cases, the police and the Coroner will be best placed to undertake an

investigation which will meet these demands. Under the Coroners’ Act 1980, there

is an obligation to conduct an inquest where there is reasonable cause to suspect

that the deceased—

(a) has died a violent or an unnatural death;

(b) has died a sudden death of which the cause is unknown; or

(c) has died in prison or in such a place or in such circumstances as to require

an inquest under any other Act.

However, there may be circumstances where coroner’s inquests have not been

convened in relation to a vulnerable adult’s death. It is possible, for example, that

deaths resulting from self-neglect might not be referred to the coroner in the first

instance, because it is not believed necessary by the medical practitioner who has

15 Korff, The Right to Life: A guide to the implementation of Article 2 of the European Convention on Human Rights, Council of Europe (2006). 16 Öneryıldız v. Turkey Application No. 48939/99. 17 Korff, at n 15. 18 Edwards v UK Application No 4647/99. 19 Kelly v UK, n 13.

9 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

been able to identify a medical cause of death. Since the failure to prevent serious

self-harm can give rise to liability under Article 2 or Article 3 of the European

Convention on Human Rights,20 it is incumbent on the Adult Safeguarding Board to

consider whether the terms of reference of an SCR ought to be defined in such a

way as to accommodate these legal demands and whether an urgent referral to the

Coroner’s office needs to be made.

It is also important to note that most SCRs do not call for witnesses or allow cross-

examination, are not conducted speedily (often delayed until the outcome of criminal

prosecutions and/or coroners’ inquests) and, where medical information requires

appraisal, are not in a position to evaluate clinical data which may cast light on the

cause of death or abuse. Moreover, their involvement of family members and other,

secondary ‘victims’ in the SCR process, is varied. For these reasons, there is cause

to doubt whether the SCR process will be compliant with all human rights

requirements, or indeed whether it is appropriate for the SCR to attempt this role.

So what do you do? Ask yourself…

Are we clear about all the other ‘investigatory’ processes taking place and their

purpose?

Have our SCR policy and procedures been endorsed by the Coroner’s office21 in

order to ensure that human rights obligations are met by the range of bodies that

may be called upon to safeguard these human rights?

Has an outline of a potential SCR, including the Terms of Reference, been

shared with the Coroner’s office in order to ascertain whether or not an inquest is

to be held?

3. Establishing the SCR Panel

“The SCR Panel includes all the IMR authors –that seems OK to us”.

“The Panel is made up of senior managers, no doubt ensuring their agency

reputation is protected or just because they want to become more familiar with

the process”

20 Keenan v United Kingdom (1998) 26 EHRR 64. 21ADASS (2005), Safeguarding Adults: A National Framework of Standards for good practice and outcomes in adult protection work, para 1.22

10 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

There are again various practices in constituting a SCR Panel. Some Safeguarding

Adults Boards have a standing subgroup/committee for SCRs and if a decision to

hold a SCR is agreed the members of the subgroup will form the core group for the

SCR Panel. In other instances Panels are brought together on an ad hoc basis with

a mix of agencies who have had some knowledge of the individual and others who

are seen as independent but may have particular expertise in the areas that appear

to be of concern. The authors of this report have experienced Panels being agreed

once IMR authors have been identified and then made up of those authors and

Panels where anyone writing an IMR is excluded from being part of the Panel!

Some SCR Panel members regard themselves as guardians of the Terms of

Reference. The presence of others may be unclear beyond being attentive to the

reputation of their agencies. While the membership of IMR authors results in

consistently informed discussions about the SCR, it may inadvertently alert agencies

to the disquiet associated with their practice. At its best however, it enables the SCR

author to explore gaps in information, test out sequencing, explanation-building,

alternative explanations and potential action points for example. There are occasions

when the representatives of agencies with peripheral or partial involvement in the

circumstances of the subject of a SCR begin to question why they have to contribute

at all.

What is important is that members of Panels have sufficient authority to speak for

their agency and sufficient professional judgement to allow them to analyse

information, accept evidenced mistakes by their own agency, and be prepared to

learn. They also need time to read materials and attend meetings, which should be

challenging and reflective rather than process and administration focussed.

Although factual accuracy is the manifest concern of the SCR author, it would be

naïve to believe that how an agency is depicted is an incidental matter. Having

engaged in a process in which participation is voluntary, agencies risk exposure,

embarrassment and loss of reputation. Further, delays dissipate urgency and yet

they are an endemic feature of SCRs. Some SCR procedures build in further delays

such as the requirement to send information by registered post as opposed to

password protected emails.

So what do you do? Ask yourself…

Who is leading on setting up the SCR Panel?

What is the rationale for the make-up of the SCR Panel?

11 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Is the SCR Panel with whom the chair/author is expected to work a Panel of IMR

authors, non-authors, or a mix of the two?

Do Panel members have a good understanding of the time and commitment to

see the job through – are they aware that once signed up that being a Panel

member is not a task to be ‘delegated’?

4. Appointing the chair and author of the SCR and

supporting the Review process

“We need an independent chair and an independent author like the children’s

model”

“We can’t afford any specific administrative support for the SCR”

The notion of independence/independent is a tricky one, particularly as none of us

would want ourselves to be regarded as biased or partial. For some, “independent“

means someone outside of our agencies – a self employed person with no axe to

grind. Of course we all know consultants/independent people like the authors of this

paper, who have biases and prejudices, some of which we would even acknowledge!

The events that lead to SCRs are very variable; some may be very specific involving

only a few agencies and over a short timescale. In those circumstances there may

be benefits in the chair and author being the same person. In a much bigger review

separating the roles may enable the process to be more efficient although we cannot

cite evidence to endorse this role separation. The degree of tension between

organisations and the public profile of the events leading up to the decision to

commission the SCR will also be factors to consider. Our experience is that the

process of conducting a SCR, never mind the public/media fallout after publication, is

not easy and the chair and author (chair/author) need to be resilient and have

access to colleague/mentor support.

Under the current and varied SCR arrangements, which mostly replicate the model

established in children’s services, authors have several critical tasks. In addition to

editing, contextualising and offering explanatory frameworks, they have to: champion

and respect a range of perspectives and ask questions, which might challenge the

legitimacy of other perspectives; bring legal and policy perspectives to bear on a

case; engage in inter-professional conversations; ensure that their work remains

factual and within the limits of the Terms of Reference; be attentive to expressions of

concern about bias and how information is represented for example; and clarify and

12 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

check with the authors of IMRs that the information they have shared is

comprehensive and accurately reflected in the SCR.

There are rarely clear stages of reading and receiving all IMRs, making sense of the

merged chronology and writing the Review. The writing begins with a contract, which

outlines the Terms of Reference. It has to accommodate implicit sensitivities and

dilemmas (such as whether to withhold sensitive, personal information), move within

and beyond the professional precincts of “safeguarding adults” to discuss with

professionals who may have been associated with the case what their explanatory

frameworks are; acknowledge what is generally known in the media about a case, as

well as attending to late emerging issues (generally ones which individual agencies

would prefer not to be shared). In our experience, detailed and extensive Terms of

Reference do not produce better IMRs. Of much greater significance to the drafting

of a SCR is the production of a merged chronology summarising events and

identifying the key personnel associated with these.

Without good administrative support and a project minded approach to the complex

task of conducting an SCR the independent chair/author will not be able to carry out

their tasks efficiently.

So what do you do? Ask yourself…

Is there agreement about what “independence” means in relation to the SCR

author and/ or chair and authors of IMRs?

Does the author have a mentor or supervisor – someone who will challenge their

critical reflection, their formulation of the lessons, their conclusions and

recommendations?

Are you clear about support/mentoring for Chair/ author, particularly if there are

information sharing/confidentiality issues?

Have the perceived merits of separating the roles of chair and author been

discussed (not least in terms of the additional cost)?

How does the Board perceive the role of the independent author?

Has the Board recruited an author who understands the distinction between facts,

comments, findings, analyses and recommendations?

13 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Does the role of the Chair/Panel include (i) instructing the author about the

organisation of the report and what the SCR should include? (ii) whether and

when discussions with IMR authors should occur? (iii) whether and when IMR

authors share their reports with each other? (iv) the content of the SCR and the

length of the Executive Summary?

Is there project management support for managing the SCR process e.g. is there

a minute taker at meetings and is there someone taking responsibility for the

circulation of minutes and other pertinent materials?

Does the local authority have the means to merge the chronologies of different

agencies?

Is there someone chasing up the delivery of IMRs?

Is there senior management support for IMR authors in their own agencies?

What have you done to familiarise senior managers across agencies with the

SCR processes?

5. Terms of Reference

“What do you mean, Terms of Reference? It’s obvious isn’t it?”

Terms of Reference provide essential boundaries to a SCR. Some run to several

pages and usually, but not consistently, authors and chairs, who are also authors,

are invited to shape these. In pre-structuring the boundaries of an SCR (including the

format of the report itself), the commissioners of the SCR indicate that there are

limits to the independence of the SCR author. Arguably however, there is a case for

setting out a broad a structure for the SCR report as inexperience in writing such

reports can impact on the delivery timetable which is an overarching concern of SCR

Panels. Clearly the SCR has to be oriented to the needs and actions required of the

contributing agencies and accordingly, should reflect detail and emphases. While it

can be helpful to consult other SCRs, or rather Executive Summaries of these, a

cursory scan suggests a remarkable variety of these in terms of the detail, the

timeframes, the implications for the associated agencies, and even their

connectedness to national policy.

It is a matter of curiosity that the Terms of Reference generally propose identifying

the subjects of SCRs as “Adult A, Mrs B, Mr C” for example, which renders the

person as an ageless ‘case’ i.e. if a SCR is to reflect something of a person’s

14 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

biography, sentences beginning, “When Adult A was six months old…” are bizzare

because the text becomes clumsy and the narrative flow is halting. Although

“confidentiality” is the unspoken rationale, this can be maintained and the person’s

uniqueness acknowledged by a pseudonym - “Mr Tom Burton, Mrs S. Bhadra,

Esther Atkin” for example. This may be negotiated with the relatives of the person

who is the subject of the SCR. Such deference to confidentiality is puzzling because

increasingly, SCRs arise from scenarios that have been given extensive coverage in

the local and perhaps national media, neither of which are hesitant about furnishing

their narratives with full names, dates of birth, addresses, and even names of

relatives and neighbours. While the Executive Summary of a SCR can provide a

corrective to inaccurate reporting in the media, this tends not to feature in the Terms

of Reference. It is appropriate to ask however, what are the legitimate boundaries of

a SCR when the internet can furnish the public with video clips of events associated

with a SCR? Furthermore, local media coverage arising from the publication of an

Executive Summary is unlikely to be as attentive to confidentiality as a SCR Panel,

chair and author. The relish with which some newspapers identify family members

and their places of residence for example is illuminating. Separately, it is likely that

blogs, which are not moderated, and which trail local reporting of SCRs may be a

source of keen anguish for families. It follows that if there is no public interest in

disclosing private information, even if this has been circulated by the mass media,

authors must be mindful not to further undermine people’s privacy.

The Terms of Reference rarely acknowledge that the Report will be scrutinised by

local authority solicitors. SCR authors may be requested to amend and remove

sections of their reports because of concerns regarding litigation. There is little doubt

that adult social care is disproportionately exposed when grieving relatives may be

contemplating legal proceedings under the law of negligence, human rights law or

criminal law.

So what do you do? Ask yourself…

Do the Terms of Reference set out a clear mandate for the SCR Panel and the

report author?

Are they sufficient to achieving the outcomes without being burdensome and

repetitive?

Are they written in plain English and understandable?

Are they feasible and realistic in terms of specificity and timescale?

15 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Is the rationale for the timeframe explained and clear for the benefit of IMR

authors ?

6. Information Sharing and confidentiality in the SCR

“We thought we had an information sharing agreement but it came unstuck

when some agencies were asked for their information about the person, who

was the subject of the SCR”

There are some circumstances, which give rise to a legal obligation on the part of

individuals or agencies to provide information (e.g. on the order of a court; on

request of a statutory inquiry; under legislation).22 The adult SCR process, however,

has no statutory basis and this makes it difficult to sustain an argument that there is

a binding obligation on the part of agencies to provide information to the SCR

Review Panel. Failure to take part in the SCR process, including sharing appropriate

information, may give rise to disciplinary proceedings/sanctions by employers, but it

is otherwise unlikely to result in a legal wrong. Moreover, there is no specific power,

which authorises the transfer of information from one agency to another for the

purposes of conducting an inquiry. Instead, it must be ascertained whether there is

consent for the sharing of information by the ‘data subject’ (i.e. the person who is the

subject of the information) or whether there is some other justification which permits

the disclosure. These issues are particularly acute when SCRs seek access to

medical information relating to victims or perpetrators. Although the legal rules differ

depending on the mental capacity of the individual to refuse disclosure of private

information, the law indicates that there is no unassailable right to confidentiality or

privacy. In each case, the right to privacy of the individual must be weighed in the

balance against other significant factors.

Information which may be classed as private (e.g. medical information) may be

disclosed with the subject’s consent or, if the subject has capacity and refuses

disclosure, if there is an overwhelming public interest in favour of such disclosure to

22 Exceptionally, it may be necessary to share information in order to discharge the State’s obligation to secure the right to life and the right to freedom from inhuman or degrading treatment. In such cases, it would have to be demonstrated that information disclosure is necessary to prevent an immediate and real risk of death or abuse. Given that the SCR is convened after a death or abuse has occurred, such obligations are unlikely to arise in this context.

16 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

the SCR. The law and professional guidance23 on confidentiality suggests that

where the subject of the medical or private information is an adult with capacity who

refuses to agree to such information-sharing, it will amount to a breach of medical

confidentiality to act against those wishes unless it can be demonstrated that

disclosure/sharing is necessary in order to address a pressing social need, such as

the prevention of death or serious harm to others.24 Whilst some perpetrators and

victims may be willing to provide SCR panels access to their medical records, others

are reluctant to do so. It may be possible to argue that the provision of the

perpetrator’s medical information is essential to address the risk of serious harm to

others. If the Terms of Reference of the Serious Case Review include the task of

determining whether current managerial and organisations frameworks (as well as

the conduct of individuals acting within them) are sufficiently robust in order to

safeguard future individuals from death or serious harm, it could be argued that such

disclosures are justified. It has been accepted, for example, that there is a public

interest in appropriate and necessary disclosure of medical records of the

perpetrator of serious criminal offences to undertake a review of events to establish

the operational issues involved in the care and management of that individual.25

Of course, it is likely that private information may already have been circulated and

reviewed within NHS investigative procedures and Individual Management Reviews

and it is possible that no further disclosure to an SCR may be deemed necessary.

There may well, however, be cases where the medical or other personal information

of a perpetrator sheds important light on the effectiveness of inter-agency co-

operation which may have contributed to the events which are the subject of the

23 See, for example W v Egdell [1990] Ch. 359 CA. Current BMA guidance reminds clinicians that their obligations to maintain patient confidentiality are not absolute: “Where health professionals have concerns about a patient lacking capacity who may be at risk of abuse or neglect, it is essential that these concerns are acted upon and information is given promptly to an appropriate person or statutory body, in order to prevent further harm”. BMA, Confidentiality and disclosure of health information toolkit, 2009. 24 Note that the GMC guidance on confidentiality states that medical practitioners “...should usually abide by a competent adult patient’s refusal to consent to disclosure, even if their decision leaves them, but nobody else, at risk of serious harm. You should do your best to provide patients with the information and support they need to make decisions in their own interests, for example, by arranging contact with agencies that support victims of domestic violence.” GMC, Confidentiality, 2009, para 51.

25 Michael Stone v South East Coast Strategic Health Authority, Kent County Council, Kent Probation Board [2006] EWHC 1668 (Admin) at 45.2. In this case, the perpetrator had given consent for his medical records to be accessed by the Independent Inquiry but opposed disclosure of his medical information to the public through the publication of the Inquiry’s full report.

17 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

SCR. In addition, the courts have acknowledged that the public interest in ensuring

the proper and efficient regulation of professions and the instigation of disciplinary

proceedings may prevail over the individual’s right to confidentiality.26 In these latter

cases it has been suggested that private medical information should not be handed

over by GPs for these purposes without prior court authorisation or patient consent.27

If the perpetrator or victim lacks capacity to make a decision about the disclosure of

medical information, then disclosures should be made in that person’s interests.28 In

determining that person’s best interests, consideration should be given to whether

the person actively objects to the disclosure of information and whether the person’s

concerns about disclosure may be addressed in some other way. If that person’s

interests are not directly in issue, disclosure may take place if, on balance, the

broader public interest prevails over the interest of the person in the information

remaining confidential. One such public interest argument would relate to the need

to ensure effective and robust practices in respect of adult safeguarding and so

information-sharing in this context, provided that private information is disclosed only

insofar as it is necessary to shed light on the issues relevant to the SCR. This is

echoed by the No Secrets guidance,29 which indicates that “it is inappropriate for

agencies to give assurances of absolute confidentiality in cases where there are

concerns about abuse, particularly in those situations when other vulnerable people

may be at risk (5.6).

Where the victim has died, the obligation of confidentiality towards the individual’s

medical record may well persist, although the courts have yet to rule definitively on

this.30 In any event, where an adult has died and there are concerns about the

26 See the case of Woolgar v Chief Constable of Sussex [2001] 1 WLR 25, where the Court of Appeal upheld the lawful disclosure of confidential information to the UKCC, elicited during a police interview and subsequent caution. 27 IN the case of a Health Authority v X, Munby J stated that “Dr X's ultimate obligation is to comply with whatever order the court may make. But prior to that point being reached his duty, like that of any other professional or other person who owes a duty of confidentiality to his patient or client, is to assert that confidentiality in answer to any claim by a third party for disclosure and to put before the court every argument that can properly be put against disclosure. All the more so when, as in the present case, he knows, because he has asked, that his patient or client is refusing to consent to disclosure.” [2001] 2 FLR 673 at [9]. The ruling was upheld by the Court of Appeal [2001] EWCA Civ 2014.

28 Note that the Data Protection Act 1998, Schedule 3 para 3 refers to legitimate processing of ‘sensitive personal data’ in such cases as being justified in the ‘vital’ interests of the person.

29 DH (2000) No Secrets Guidance on the development and Implementation of Multi-agency Policies and Procedures London: HMSO 30 See, in particular, Lewis v Sec State Health [2008] EWHC 2196.

18 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

operational involvement of safeguarding agencies and personnel, it is likely that the

public interest arguments in favour of disclosure will prevail, provided that the

‘onward’ sharing of information from health sector to the SCR will continue to

preserve the confidential nature of the medical information and make available in the

public domain only that information which is vital to fulfilling the terms of reference of

the SCR.31

So what do you do? Ask yourself…

Do we have an information sharing protocol that includes sharing information for

the purposes of a SCR or another reviewing vehicle?

What are our experiences so far of sharing information across agency and

professional boundaries, bearing in mind nationally identified challenge of GPs’

onward dissemination of medical information within the bounds of the law on

confidentiality and data protection?

Do the Terms of Reference consider the risk of harm to others as a result of

sharing information/not sharing information?

Was the mental capacity of the victim or perpetrator assessed with regards to

specific decisions concerning the sharing of information?

7. Commissioning Individual Management Reviews

“We need to start now and get as many Individual Management Reviews

(IMRs) in asap – written by independent people - obviously”

“They (IMR authors and agency representatives) all seem to be saying that it’s

all right now because the lessons were learned before the SCR was

commissioned”

Boards may be unaware of the implications of drafting IMRs – most particularly for

agencies, which are unfamiliar with the process, including some NHS professionals

and those in smaller private or voluntary sector agencies. There is frequently no

protected time for employees asked to produce chronologies and narrative

31 Lewis v Secretary of State for Health, above.

19 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

summaries of the decisions and actions of their colleagues. (Some agencies are so

small that the person identified to write the IMR may have had some contact with the

person whose circumstances are the focus of the Review). Furthermore, the

timeframe of the SCR is crucial. The task is huge if authors are requested to scan

records arising from the previous ten years. Even if the timeframe is more modest,

the circumstances of a person who is receiving a service may occupy several

volumes of case notes.

IMR authors access written information and they may interview individuals who

worked with the subject of the SCR. Although records are only partial and selective

accounts of events, they are embedded in the processes that created them,

including the rules about their content, how they were organised, archived, and

made available. They may not even be in institutional storage. Furthermore, staff

leave and retire and may/ may not recall their decision-making regarding a former

client.

To set aside potential allegations of bias, some Directors of Adult Social Care

propose that the IMR should be compiled by a person entirely independent of the

authority and such authorities may refer to Independent Management Reviews. In

the reporting of a SCR, the merits of independence are rarely acknowledged. The

task of reading IMRs confirms that few practitioners are experienced in writing

reports and some struggle to express ideas in a concise manner. The limitations of

the IMRs may become apparent during (i) Panel discussion with the IMR authors as

individuals or in groups (bearing in mind that not all Chairs/Panels invite independent

authors to engage in Panel discussion) – which may/may not be minuted and (ii)

writing the overarching report when information gaps appear glaring.

Panel discussions with IMR authors require careful facilitation and sometimes,

inadvertent mediation if the disputes which prevailed in the provision of a person’s

service are re-visited in SCR meetings. Attendance at these meetings may vary with

some IMR authors absenting themselves, only to return once they have read the

draft of the SCR. Without exception, the formerly absent IMR authors challenge the

sections of the draft which pertain to their agency. This may be accompanied with

lobbying by telephone and email, occasionally involving senior managers with an

identical request, “Please remove XY and Z…please substitute the third

recommendation with...” How individual agencies are depicted is a matter of far

reaching concern to all contributing agencies, not least as a SCR invariably exposes

fault-lines. Necessarily agencies have a self-activation impetus and undertake their

own rapid reviews, although these tend not to be shared with SCR authors. This

enables them to claim prematurely and on the basis of short term corrections alone

that “lessons have been learned.” Typically, there is rarely a neat chain of events;

rather, there are critical moments, large and small. Typically, also, policies,

procedures, and practice evolve, practitioners and managers change, and by the

20 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

time that a SCR’s Executive Summary is published, organisations may appear to

have substantially changed.

Attaining effective learning and development in the workplace and beyond is a major

concern of organisations. It engages with bodies of knowledge and the use of

analytical thinking. It is concerned too with the capabilities people have to achieve

performance and with patterns in employees’ behaviour so that desired and

expected performance is achieved.32

So what do you do? Ask yourself…

Has the SCR Panel specified that the chronology of contacts, the personnel

involved, the rationale and decision-making about these, must be completed

within an agreed timetable?

Is the timeframe broadly informed by what is known of the quantity of information

held in case records across agencies?

Has the SCR Panel encouraged agencies to nominate IMR authors who are

known to write credible reports?

Have you considered the independence/independent question for IMR authors?

Do you have someone to provide some support for smaller/less experienced

agencies to prepare their IMR?

Are you attuned to the dangers of promoting simplistic and premature claims and

conclusions?

Have you/the Panel asked for evidence of the outcomes of changed

practice/activity rather than the intentions?

8. Involving Family Members and Significant Others

“What about the relatives? Has anyone been in touch with them”?

“This is going to take for ever if we try to talk to the relatives”.

32 Gibb, S. (2002) Learning and Development: Processes, Practices and Perspectives at Work Basingstoke: Macmillan Palgrave

21 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Few SCR Executive Summaries reference contact with the relatives/significant

others of people who have been harmed or have died. It may be unrealistic to

demand contact as part of the Terms of Reference because being unduly

prescriptive or directive cannot take account of: the diversity of relatives’ agendas;

other urgent priorities which may overshadow their responses to the abuse; or the

possibility that there is some form of review taking place may be all too emotionally

distressing. There are acute challenges too when relative(s) have been directly or

peripherally associated with the neglect or abuse. There should be an expectation

that relatives/significant others should be informed that there is to be a SCR, how

this is done is crucially important. Families/significant others are the ultimate decision

makers regarding their priorities and life choices and some may be explicit that they

want “heads to roll” for example. Acknowledging them as potential key individuals

does not mean that they will want to play a major part but they need to be given

choice about the frequency and content of their involvement. During a crisis, some

relatives may seek intensive supports whereas others may prefer to be left alone to

cope as a family. Meetings for groups of relatives may be inadvisable due to likely

tensions and not least because of constraints in families’ time and resources.

So what do you do? Ask yourself…

Are the contact details and key information of relatives/significant others,

including health/potential increased vulnerability up to date?

Are there practitioners who know the relatives, who are familiar with their

linguistic and socioeconomic backgrounds, who can negotiate ways of supporting

relatives for the duration of the SCR?

Do we have clear written materials that can explain the process?

Given that a “SCR” is professional jargon, have you considered how to explain

the process in a way that makes sense to a layperson and is unbiased?

Has careful attention and consideration been given to the circumstances of

relatives/significant others, including how their action/inaction may be identified

through the SCR?

What scope is there for discussing the findings with relatives and significant

others before the publication of the Executive Summary?

22 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

9. Making findings public

“Do we have to publish the SCR?”

Adult SCRs are not made publicly available in full, irrespective of the determination

to do so with regard to children’s SCRs since June 2009 (prior to the Munro Review).

There is scant evidence that the lessons to be learned from SCRs are disseminated

effectively at local, organisational levels. This begs the question of the efficacy of

the SCR process, if indeed the goals are to establish the circumstances leading to a

death or serious incident, to learn lessons from these and to make changes at

operational and strategic levels in order to reduce the likelihood of their recurrence.

Two human rights are typically held in tension when it is proposed to make public

information about a serious incident involving vulnerable adults. The ‘right’ to

freedom of expression, which embraces more significantly here the right of access to

information, and the right to respect for privacy. English law has made clear on

repeated occasions that neither of these rights triumphs over the other. In each case,

it is to be decided where, on the available information, the balance of interests lie.

Whilst there may be considerable public interest in ensuring accountability of

professionals and systems through the publication of a full report which details the

circumstances of the death or abuse of an individual, 33 these are not the stated aims

of a SCR. Whether this interest can only be fulfilled through a full, un-redacted

version of the SCR report will depend on the circumstances of each case.

It has been suggested that the most recent guidance relating to independent

investigations into homicides by users of mental health services indicates that the

presumption lies in favour of disclosure of the whole report, without anonymity for

professionals whose conduct is expressly referred to.34 Even if this presumption

were accepted in law,35 it is arguable that this presumption is inappropriate in the

33 Indeed, this argument was accepted by the High Court as one of the relevant considerations in determining that the public interest in favour of disclosure should over-ride Michael Stone’s wish for the full Independent Inquiry report into his homicides to be made public: Stone v South East Coast Strategic Health Authority [2006] EWHC 1668 (Admin) [45] . The goals of such an investigation are to ‘facilitate openness, learning lessons, creating change”: Department of Health, Independent investigation of adverse events in mental health services, 2005. Of particular significance in that case is the expressed wish of the Investigation panel members that the full report be made publicly available. 34 Scott-Moncrieff and Marsden, “’Publicity v Privacy: finding the balance’. When and how to publish reports of mental health homicide independent investigations’ (2009) J Mental Health Law 128. 35 The presumption has never been explicitly tested and, as Moncrieff and Marsden indicate, is subject to rebuttal where anonymity might be necessary for ‘the prevention of disorder or

23 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

SCR process, since the SCR will most likely contain considerable personal

information about the circumstances of the victim of any alleged crime.36 Where a

high-profile, widely-publicised case becomes the subject of a SCR, the public

interest in making the circumstances surrounding the events available may be

greater. Indeed, the arguments in favour of maintaining privacy may also be

weakened if there is already a significant amount of private information about the

case already in the public domain. The publication of identities of staff involved in

the care of a vulnerable adult in any document made public to the world at large

would be particularly problematic in the SCR context. Section 10 of the Data

Protection Act 1998 allows individuals to object in writing to the processing of their

personal data where that processing causes them substantial distress or harm. That

objection, however, may be over-ridden where the processing of data, without

consent, is necessary ‘for the exercise of functions of a public nature performed in the

public interest’. If the primary public interest in the publication of an SCR report or

summary is to learn lessons from an adverse event and to suggest changes to the

procedures and processes that exist within and across services, a strong argument

can be made that the disclosure of staff identities is not essential to this function.

Even if, as Moncrieff and Marsden suggest, the law were to endorse a presumption

in favour of staff identification, that presumption could be set aside in cases where

anonymisation is necessary to protect the rights and freedoms of those staff

members, in accordance with Article 10(2) ECHR. Given that, colleagues named in

a report have not typically had the opportunity to present evidence directly to the

SCR Panel or, to challenge contradictory evidence, as would be the case with a

statutory inquiry, their reputations, and potentially their safety may be severely

compromised by such disclosures.

So what do you do? Ask yourself…

Is there a well-communicated media strategy that contemplates not only the dissemination of relevant findings from the SCR but also how questions and responses will be dealt with.

Is it appropriate to make available different layers of information to different

stakeholders (family members; staff; and the media)?

crime, the protection of health or morals, or the protection of the reputation or rights of others”, above p 135. 36 It was considered a significant factor in the Michael Stone case, that Michael Stone was responsible for the criminal conduct that had set in motion the need for an independent investigation. Clearly, this cannot be said to be the case in respect of the majority of SCRs.

24 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Do family members/significant others and victims and have a clear picture of what happened and how agencies responded to events?

If medical or other sensitive information is shared beyond the confines of the SCR panel, do the goals of publication meet a pressing social need to protect the health or the rights and freedoms of others and is the information absolutely necessary in order to achieve this goal?

Have the analysis, the conclusions, the learning and action points been disseminated widely among those with operational and strategic responsibility for safeguarding within relevant agencies?

If a decision is made to publish, have we fully considered the impact on family

members/relevant staff and have we provided them with immediate support

following publication?

10. Learning the lessons

“How can we be sure this won’t happen again?”

In this paper we have presented a series of question-prompts. These challenge the

perception that serious case reviewing can be streamlined, structured, codified, and

constrained. More broadly, the questions acknowledge the fundamental

responsibility of organisations to promote continuous and cumulative professional

learning across contexts. Although few would take the view that learning in adult

safeguarding hinges on the reception of information from SCRs, as co-learners and

co-participants in the preparation of this paper, we endorse strongly a conception of

learning as a participative process. Minimally, the distinctive events regarding the

harm of adults whose support needs may or may not be known to adult social care

services give Safeguarding Adults Boards and practitioners a reason to learn and a

purpose to engage in collaborative professional development practices. This is some

distance from “awareness raising” training events which neatly distinguish different

kinds of abuse.

Some of the concerns raised by SCRs may be very specific to particular practitioners

and/or localities. However, the findings of these ‘outside’ provided case studies will

resonate in most localities and across professional groups. SCRs identify the

requirement for work-embedded support if they are to promote on-going professional

development efforts. The best scenario involves the high interest of managers and

practitioners across disciplines in exploring and considering the meaning of SCRs,

without creating a feeling of work overload.

25 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

The reporting of SCRs takes professional learning into new locations and unfamiliar

arenas. Since internet technology is pervasive and cheap, learning about issue-

specific, adult protection concerns can take advantage of diverse and global

intellectual currents. The proliferation of learning vehicles include not only the media

reporting of the harms and distress of adults who could not protect themselves, (the

headline, “Tragic torment of lonely misfits” comes to mind from almost 30 years ago

when a research report about deinstitutionalisation in North West England was

published), but also virtual materials - the blogging shouts of indignation; tantalising

glimpses of police interviewing the perpetrators of crimes; images of relatives

describing their trauma, images taken by perpetrators as they commit their crimes;

and images of the graves of their victims. Such means continue to shape

perceptions about adults at risk of harm and the roles of their relatives and service

providers.

SCRs can constitute a deliberate “other” voice – one that does not minimise the

critical findings or seek to judge those associated with crimes against adults who

could not protect themselves. Safeguarding Adults Boards bear the moral burden of

ensuring that all individuals associated with abusive insults are portrayed in ways

that do not fuel voyeuristic and vengeful reporting. There are also other, compelling

voices, including the testimony of those who have endured atrocities and trauma.

The task is not to immerse ourselves in securing “feedback” from adults who have

received a safeguarding service but rather to cultivate and, with their permission, find

ways of describing their motivation to keep going – and this can and should occur in

different ways.

So what do you do? Ask yourself…

Do we have a meeting/process planned to learn from the experience of doing the

Review, or do we just move on to the next/hope there won’t be another one?

How will recommended changes in service planning and delivery, professional

development and inter-agency working be audited and evaluated to determine

whether lessons have indeed been learned?

How will information about these outcomes be shared in ways which are

meaningful to the diverse array of stakeholders.

Is there a case for hosting a workshop for practitioners and managers,

collectively or on an organisation-by-organisation basis to reflect on events and

determine what needs to happen to reduce the likelihood of similar events

recurring in the immediate and long term future?

26 FLYNN, KEYWOOD AND WILLIAMS 30 May 2011

Where the abuse/neglect has involved a community/institution or individuals

in a group setting, including a family are there ways of enabling broader

learning to take place?37

37 Tameside Adult Safeguarding Serious Case Review Adult A March 2011.