Learning from Safeguarding Adults Reviews The Case of Ms F Purpose of the Safeguarding Adult Review Safeguarding Adult Reviews (SARs) are about learning lessons for the future. They will make sure that Safeguarding Adults’ Boards get the full picture of what went wrong, so that all organisations involved can improve their practice. Organisational systems are complex. Therefore findings are not presented as recommendations but as a series of problems and puzzles for consideration and local prioritisation. A case review plays an important part in efforts to achieve safer and more effective systems. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies. Case Review findings say something more about local agencies and their usual patterns of working. They exist in the present and potentially impact in the future. It is important that local agencies review the findings from a Safeguarding Adult Review and consider what changes can be made in local processes and practices to prevent such a case reoccurring. Succinct summary of case Ms F was a young woman who died of sepsis. With the exception of her GP, her case was not open to any service until just before her death, when she was referred to Adult Social Care by the Police. Other members of the household were well known to many services in Reading including Antisocial Behaviour and the Police, both as victims and perpetrators. Findings FINDING 1 In Reading, the Multi-Agency Pathway for non-engagement is not consistently followed, with the consequence that multi-agency perspectives and resources are not brought to bear when previously-managed risk becomes less controllable. SUMMARY Reading has substantial numbers of adults who are either vulnerable or at risk, and who do not engage with services. Whilst this Safeguarding Adults Review was under way, the Safeguarding Adults’ Partnership revised and re-launched an existing pathway to try and increase the likelihood of professionals, led by a senior practitioner, thinking collectively about possible new solutions in each instance of non-engaging adults where risk starts to increase. If practitioners and their managers are not familiar with the pathway, it cannot drive improvements. Questions How do practitioners view the issue of non-engagement? How much of a block and a risk is it to the local safeguarding adults’ system? What attempts have there been to tackle the safeguarding risks that can come with non-engagement?
Learning from Safeguarding Adults Reviews The Case of Ms F Purpose of the Safeguarding Adult Review Safeguarding Adult Reviews (SARs) are about learning lessons for the future. They will make sure that Safeguarding Adults’ Boards get the full picture of what went wrong, so that all organisations involved can improve their practice. Organisational systems are complex. Therefore findings are not presented as recommendations but as a series of problems and puzzles for consideration and local prioritisation. A case review plays an important part in efforts to achieve safer and more effective systems. Consequently, it is necessary to understand what happened and why in the particular case, and go further to reflect on what this reveals about gaps and inadequacies. Case Review findings say something more about local agencies and their usual patterns of working. They exist in the present and potentially impact in the future. It is important that local agencies review the findings from a Safeguarding Adult Review and consider what changes can be made in local processes and practices to prevent such a case reoccurring. Succinct summary of case Ms F was a young woman who died of sepsis. With the exception of her GP, her case was not open to any service until just before her death, when she was referred to Adult Social Care by the Police. Other members of the household were well known to many services in Reading including Antisocial Behaviour and the Police, both as victims and perpetrators. Findings FINDING 1 In Reading, the Multi-Agency Pathway for non-engagement is not consistently followed, with the consequence that multi-agency perspectives and resources are not brought to bear when previously-managed risk becomes less controllable. SUMMARY Reading has substantial numbers of adults who are either vulnerable or at risk, and who do not engage with services. Whilst this Safeguarding Adults Review was under way, the Safeguarding Adults’ Partnership revised and re-launched an existing pathway to try and increase the likelihood of professionals, led by a senior practitioner, thinking collectively about possible new solutions in each instance of non-engaging adults where risk starts to increase. If practitioners and their managers are not familiar with the pathway, it cannot drive improvements. Questions How do practitioners view the issue of non-engagement? How much of a block and a risk is it to the local safeguarding adults’ system? What attempts have there been to tackle the safeguarding risks that can come with non-engagement?