Brighton & Hove Safeguarding Adults Board

1. Brighton & Hove Safeguarding Adults Board How Can We Learn From Serious Case Reviews Nick Georgiou 14 September 2012

2. Brighton & Hove Safeguarding Adults Board Want to look at why this is important to you • The broader picture • The process and how to make it as positive and worthwhile as can be • You have local experience here in Brighton, so also want to look at what you have done locally Nick Georgiou 14 September 2012

3. Brighton & Hove Safeguarding Adults Board What do we know about SCRs? • Triggers • Messages • What does it mean for the agencies? Nick Georgiou 14 September 2012

4. Brighton & Hove Safeguarding Adults Board Why is this important to you? Learning Shared process and experience Board’s purpose and responsibility Achieving change Showing that you are doing something Working positively with colleagues in your own and partner agencies Make the process positive, managing defensiveness Nick Georgiou 14 September 2012

5. Brighton & Hove Safeguarding Adults Board What’s involved in a SCR? • Deciding that an incident merits a SCR • Appointing an Independent Chair, and the implications of that • Terms of Reference • Individual Management Reviews • Panel Meetings • Report drafting • Presentation to the Board • Relatives • Staff • Media interest • Action Plan • Monitoring Nick Georgiou 14 September 2012

6. Brighton & Hove Safeguarding Adults Board Getting maximum value from a SCR • Costs • Understanding • Learning • Improvement • Joint working Nick Georgiou 14 September 2012

7. Brighton & Hove Safeguarding Adults Board Setting up the Serious Case Review SCR Request and Agree the need for a SCR Appoint an Independent Chair Terms of Reference Identified agency managers to provide IMRs Incident prompt for a possible SCR Nick Georgiou 14 September 2012

8. Brighton & Hove Safeguarding Adults Board The SCR Panel, producing a report and Action Plan • Panel meeting 1 • Get the IMRs in good time • SCR panel made up of senior staff from local agencies • Independent Chairs job is to to manage and drive the process • Identify what other information you need and who to get it from • Next Panel • meeting(s) • Go through the IMRs, what do you learn from them? • Go through the considerations to promote analysis and possible recommendations • Chair to draft report for discussion at next meeting • Final Panel meeting • Discuss draft report • Identify Findings and recommendations • Develop an Action Plan to present to the Board • Work out communication with • Relatives • Media • Draft the Executive Summary Nick Georgiou 14 September 2012

9. Brighton & Hove Safeguarding Adults Board Ownership and Action Presentation to the SAPB Board and Ownership Media interestDissemination Learning Reviewing the Action Plan Nick Georgiou 14 September 2012

10. Brighton & Hove Safeguarding Adults Board Your local experience • Death of a disabled man killed in April 2011 • Very chaotic lifestyle, street drinker, had mental capacity • Known to services and well supported by home care agency, in supported housing • Frequent attender at A&E, often taken there by Ambulance service, Police had numerous call-outs to the address either to him or to others staying/visiting there, subject to Safeguarding actions • Well liked and considered to be vulnerable Nick Georgiou 14 September 2012

11. Brighton & Hove Safeguarding Adults Board Followed the SCR process • Panel meetings, identified early on that we should ask both the hospital and Ambulance service to join the panel • Identified that this was a case where you could take learning beyond the specifics and affect services more generally • Good open discussions and shared working through of issues • Identified where others could also make a contribution and extended membership so that we could generate an understanding and actions that the agencies would own and work together to achieve their implementation Nick Georgiou 14 September 2012

12. Brighton & Hove Safeguarding Adults Board • SCR panel produced 9 recommendations drawn from the specifics of the case but which are also more widely applicable • When the SCR report was presented to the Board we also presented an Action Plan which continues to be monitored to promote the achievement of the recommendations, some of which are hard to implement • Monitoring delivery of the recommendations by the Board Nick Georgiou 14 September 2012

13. Brighton & Hove Safeguarding Adults Board So what did you learn? • Lot of shared understanding and identification of common interests and issues to sort out to achieve more cohesive services • Some specific service and practice changes • Drawing from the particular case the potential to do some things differently, eg on managing risk across the range of specific systems for identifying risks and supporting vulnerable people • Recognising people who make a lot of call on services showing a possible trend and need to share and escalate involvement by the agencies Nick Georgiou 14 September 2012

14. Nick Georgiou 14 September 2012