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WHAT CAN WE LEARN FROM COMPLETED SARS?

Explore important learnings from completed SARS, recommendations for prevention, organizational factors, and interagency cooperation to enhance safeguarding adults practices. Gain insights on common themes and contact points for safeguarding referrals.

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WHAT CAN WE LEARN FROM COMPLETED SARS?

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  1. WHAT CAN WE LEARN FROM COMPLETED SARS? FINDINGS FROM TWO THEMATIC REVIEWS UNDERTAKEN BY MICHAEL PRESTON-SHOOT

  2. Care Act 2014: statutory duty to review serious cases • An SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if…

  3. SAR Statutory Duty • there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and • (a)the adult has died, and • (b)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).

  4. SAR Statutory Duty or • the adult is still alive, and • the SAB knows or suspects that the adult has experienced serious abuse or neglect. • An SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

  5. Focus of Studies • What learning themes emerge? • How does the learning help us understand what goes wrong? • What changes are recommended in order to prevent recurrence? • Sample 38 SARS • 12 organisational abuse • 13 self neglect • 7 combined involving neglect with self neglect

  6. Direct Practice With the Adult

  7. Direct Practice With the Adult

  8. Organisational Factors

  9. Organisational Factors

  10. Interagency Cooperation

  11. Interagency Cooperation

  12. Conclusions • Unique and complex pattern of shortcomings • Learning rarely confined to poor practice • Weaknesses in all layers of the system • Taken together they add up to a ‘fault line’

  13. Next Steps Locally • Following related safeguarding adults forum we will • Disseminate information via different methods including • Chair of the Board newsletters • Podcasts • Posters • Forum engagement

  14. Next Steps • TSAB will review completed action plans within agreed timescales to check on how well SAR recommendations have been implemented - ‘so what’s changed in reality’ • TSAB is reviewing its governance systems for the commissioning, management and reviewing of safeguarding adult reviews.

  15. Next Steps • We are working with regional ADASS to produce consistent guidance on common themes such as • Threshold guidance • Risk Assessment • Self neglect

  16. Safeguarding Contact Points • To raise an adult abuse safeguarding referral please contact 01803 219888 or safeguarding.alertstct@nhs.net • To make a safeguarding adult review referral contact 01803 219760 or tsdft.torbaysafeguardingadultsboard@nhs.net mark subject as SAR referral • Julie Foster – Independent Chair, Torbay Safeguarding Adults Board. Contact via 01803 219760 or tsdft.torbaysafeguardingadultsboard@nhs.net • Jon Anthony – Torbay Operational Lead 01803 219831

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