Safeguarding Adult Review (SAR) Policy & Procedures

The Care Act 2014 created a new legal framework for Adult Safeguarding, this included outlining the circumstances in which Safeguarding Adults Boards must arrange a Safeguarding Adults Review (SAR).

The purpose of this policy and procedure is to outline the principles and definitions that support the commissioning and undertaking of SARs and to describe the statutory duties set out under Section 44 of the Care Act 2014. This procedure is supported by the Teeswide Inter-agency Policy and Procedures and the individual policy and procedural guidance of each partner agency.

This procedure applies to all partners of the Teeswide Safeguarding Adults Board and to any other professional or organisation involved at any stage of the SAR process, from submitting a SAR Notification through to completing actions derived from the review.

It should be noted that in addition to this policy and procedure an administration process is held by the TSAB Business Unit.

A Safeguarding Adults Review is a statutory requirement of the Care Act 2014 (Section 44).

The purpose of a SAR is to:

• Determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death
• Learn lessons from the case and apply the learning to future cases to prevent similar harm occurring again
• Explore examples of good practice where this is likely to inform and improve inter-agency practice.

A SAR is not to hold any individual or organisation to account or to apportion blame: other procedures exist for that and include criminal proceedings and disciplinary procedures.

It is also recognised that individual organisations will have their own internal or statutory review procedures to investigate serious incidents. This procedure is not intended to duplicate or replace these.

This procedure reflects the six safeguarding principles described in The Department of Health, Care and Support Statutory Guidance issued under the Care Act 2014, that underpin all safeguarding adult work.

• Empowerment
• Prevention
• Proportionality
• Protection
• Partnership
• Accountability

In addition, the Care and Support Statutory Guidance outlines a number of principles to be followed by Safeguarding Adults Boards and their partner organisations when undertaking Safeguarding Adults Reviews:

• there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the well-being and empowerment of adults, identifying opportunities to draw on what works and promote good practice
• the approach taken to reviews should be proportionate according to the level of complexity of the issues being examined
• reviews should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed
• professionals should be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith
• families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

The Care Act 2014 sets out the criteria for carrying out a SAR and SABs must carry out a review if:

1. There is reasonable cause for concern about how the Safeguarding Adult Board (SAB), its members or other persons involved worked together to safeguard the adult; and
2. The adult has died, and it is known or suspected that the death resulted from abuse or neglect, including self-neglect; or
3. The adult is alive, but it is known or suspected that they have experienced serious abuse or neglect, including self-neglect

In relation to Point iii. above, the Care Act 2014 defines that ‘something that can be considered serious abuse or neglect where, for example, the individual would have been likely to have died but for an intervention, or has suffered permanent harm, or has reduced capacity or quality of life. This could be because of physical or psychological affects as a result of the abuse or neglect’.

SABs can also carry out a SAR in any other situations involving an adult in its area with needs for care and support and there is value in doing so: this is called a discretionary review.

The Care Act 2014, Section 45 creates a legal duty for any agency or person to share what they know with the Safeguarding Adults Board (SAB). The test is that the information requested by the SAB must be for the purpose of enabling or assisting it to perform its functions, including that of undertaking Safeguarding Adults Reviews. This means that if a SAB requests information from an organisation or individual who is likely to have information, which is relevant to the SAB’s functions, they must share what they know with the SAB.

All information sharing will be carried out with regard to the Caldicott Principles, Data Protection Act, General Data Protection Regulations and the TSAB Information Sharing Protocol.

Any emails sent or received as part of the review process must be sent securely, if necessary, the Egress system will be used to transfer secure records between agencies and the reviewer. All documentation and records provided to TSAB or created as part of a review will be held securely by the TSAB Business Unit and disposed of in accordance with Stockton-on-Tees Borough Council’s Retention Policy. Agencies will not hold records relating to SARs on individual’s case records

• Ensuring TSAB meets its statutory responsibilities in relation to SARs
• Reviewing the recommendation made by the SAR Sub-Group following a SAR notification and deciding on the action to be taken
• Appointing suitable independent individual(s) to lead the SAR or other learning review in conjunction with the SAR Sub-Group Chair
• Considering whether specialist advice is required to help understand any specific aspects of the case.

• Receiving and considering regular reports on the progress of reviews from the SAR Sub-Group
• Receiving and approving the final draft of the review report prior to publication
• Receiving assurance form the SAR Sub-Group that multi-agency action plans resulting from SARs and other reviews are implemented
• Ensuring there is sufficient funding available to commission SARs and other types of review.

• Fulfilling the statutory duty in respect of SARs and ensuring reviews are completed in line with the SAR policy and procedures and the SAR Quality Markers
• Considering all SAR Notifications
• Making recommendations to the TSAB Independent Chair on the actions to be taken following consideration of a SAR Notification
• Allocating a Key Worker to maintain contact with the adult, family and/or representatives
• Making recommendations about how the adult and/or their representative should be involved including whether they need an advocate
• Ensuring that all reports, action plans and learning briefings are presented to the TSAB for approval
• Working closely with the relevant Sub-Groups and partners to ensure that any recommendations from a review are fully implemented
• Providing regular progress updates on action plans to TSAB meetings
• Considering how the interfaces between other reviews/proceedings should be managed in order to maximise learning and to avoid duplication

The SAR Governance Group will be independent of the case and comprise: the appointed Reviewer, TSAB Independent Chair, SAR Sub-Group Chair, SAR Sub-Group members, Senior Managers from organisations involved in the delivery of services to the adult, Key Worker, TSAB Business Unit Manager, SAR Co-ordinator and admin support.

• Members of this group must be of appropriate seniority in their organisation to ensure they are able to the fulfil this important role in the review process
• Agreeing the scope of the review
• Overseeing the SAR/ other type of review in accordance with the agreed scope, terms of reference and methodology
• Ensuring appropriate involvement of professionals and organisations that were involved with the adult
• Obtaining legal advice about any aspect of the review, where required
• Considering how to liaise with the adult, family and/or their representative
• Ensuring internal approval processes are carried out and confirm factual accuracy of the final report on behalf of their organisation prior to it being presented at TSAB
• Resolving any challenges in relation to the report prior to it being agreed at the TSAB meeting
• Considering the final report and recommendations prior to approval at Board
• Determining how the report will be published

• Facilitating discussions when a notification is being considered at the SAR Sub-Group
• Approving the SAR Recommendation Summary prior to being submitted to the Independent Chair for a final decision
• Leading discussions at the Initial Scoping meeting
• Supporting the Independent Reviewer commissioning and recruitment process
• Attending an initial meeting with the Independent Reviewer to discuss the review
• Being a member of the SAR Governance Group
• Providing updates on the review to TSAB meetings

• Leading on the commissioning and sourcing of independent reviewers
• Providing admin support and co-ordination of the review
• Monitoring and recording of actions, evidence and progress associated with reviews

• Ensuring appropriate advocacy is sourced and available for the adult if they are still alive
• Sourcing legal advice, if required
• Leading and co-ordinating on media interest, press releases

• Attending learning and reflection workshops
• Reflecting on their own practice and the systems in place when working with the adult

Some methodologies, but not all, require the development of a single agency report (often referred to as an Independent Management Report (IMR)). Authors of these reports will be identified by Senior Managers from their own agency, and they will not have been directly involved in the delivery of care and support to the adult. They are responsible for:

• Introducing the SAR to practitioners
• Speaking to practitioners as well as using records to formulate the single agency report
• Reflecting on practice, providing a sound analysis of what happened in the case, and why from their agency’s perspective
• Ensuring all questions in the terms of reference are considered
• Highlighting good practice
• Being person-centred
• Suggesting what needs to happen in order to reduce the risk of recurrence
• Providing SMART recommendations for their agency
• Ensuring the single agency report has been approved prior to submitting it on time

If a single agency report is not required an Agency Representative may be nominated to provide the link between the review and practitioners.

The allocated key worker will usually be identified at the SAR Sub-Group meeting at the point of a review being agreed and wherever possible will be independent of the case. Where an advocate has been appointed to support the adult, it may not be necessary to also appoint a Key Worker

The Sub-Group members will carefully consider on a case-by-case basis who the best person is to undertake this role.

The key worker’s responsibilities include:

• Communicating with the adult or the family on the progress of the review at each stage including how the adult/family can engage with the review
• If required, supporting the Independent Reviewer in engaging with the adult or the family throughout the review
• Ensuring the adult or family members understand the purpose and focus of the review particularly in relation to the final report

If the adult is alive, they must be asked if they would like to be involved with the SAR process and then kept informed at each stage of the SAR process from the initiation of a SAR Notification through to the publication of the report in accordance with their wishes.

It is important that discussions take place at an early stage with the adult and/or their representative to agree how they would like to be involved in the process, using the principles of Making Safeguarding Personal (MSP), the Mental Capacity Act and Best Interest decisions.

Where the adult has mental capacity, the involvement of family, friends or informal carers should be agreed with the adult.

Where the adult does not have mental capacity; family, friends or informal carers should be consulted and involved in the review process, if they wish.

There is a statutory duty to ensure that if the adult is still alive they receive the support they need to help them to understand and participate in the SAR process. Where an Independent advocate has already been arranged under Section 67 of the Care Act 2014, the Mental Capacity Act 2005, or the Mental Health Act the same advocate should be used unless for good reason this is deemed to be inappropriate. Each case will be considered on an individual basis and in the context of Making Safeguarding Personal, appropriate support will be provided as required, recognising that there may need to be some flexibility to meet individuals needs and preferences, and to address resource availability.

a. Anyone can submit a SAR Notification using form (SAR01) if they consider that the Care Act 2014 criteria for a SAR is met. If a family member wishes to submit a notification for consideration, they may use the SAR01 or alternatively they may submit their request in writing to the Independent Chair via the TSAB Business Unit who will liaise to request a formal notification is submitted.

b. A SAR Notification may be initiated as an outcome of a Section 42 Enquiry. If the adult and/or family members are present at the enquiry and are therefore aware that a SAR Notification is to be submitted, care must be taken to explain what the purpose of a SAR is and to ensure they have an understanding of the next steps of the process.

c. The SAR01 form can be found on the TSAB website and must be fully completed include relevant and factual information, provide contact details for all agencies involved, include a rationale on how the case meets the SAR criteria. and signed by the notifier.

d. The notifier must follow their organisation’s internal processes prior to submitting the notification and wherever possible the notification should be forwarded to the TSAB Business Unit by the agency’s TSAB member. Where this has not been possible, the TSAB Business Unit will ensure that the TSAB member has been notified. Please note this does not apply when a SAR Notification has been submitted by a family member.

e. All notifications for consideration must be submitted to the TSAB Business Unit.

f. On receipt the TSAB Business Unit will:

• If the SAR01 is incomplete, it will be sent back to the notifier and more information will be requested.
• Confirm receipt of the SAR01 to the relevant TSAB member and/or referrer
• Screen the information received against the SAR Decision Support Guidance and the Care Act 2014 criteria
• Inform the TSAB Independent Chair that a SAR01 has been received

g. If the SAR01 appears to meet the SAR criteria or warrants further discussion, then the Notification will be progressed to the next stage.

h. If the SAR01 clearly does not meet the SAR criteria, then the referrer and lead Local Authority will be informed.

i. If the adult or family are aware of the notification being submitted, they must be advised of the outcome by the notifier.

a. The TSAB Business Unit will consider the SAR01 and determine the specified dates for the Initial Chronologies based on information from the SAR01 and with a focus on key dates.

b. All Sub-Group members will be sent a copy of the completed SAR01 and asked to complete an Initial Chronology Form SAR02, outlining their involvement with the adult between the specified dates and include any historical information which may be relevant.

c. Agencies should include details of all relevant events and interventions between the specified dates, including whether the adult was seen

d. Agencies who were involved in the case but not members of the SAR Sub-Group will receive an email requesting they complete the Initial Chronology Form SAR02.

e. The SAR02 must be completed in the specified format to ensure the TSAB Business Unit are able to easily extract and collate the information. A clear deadline for returning the SAR02 will be given.

f. If the agency has not been involved with the adult; they must submit a nil return.

g. The SAR02 must be returned via a secure email, or through Egress if security of the information cannot be guaranteed, or password protected if there is no other means of securing the content of the form.

h. The TSAB Business Unit will collate the Initial Chronologies into one document in chronological order.

a. The SAR01 must be considered by the SAR Sub-Group within 28 days of receipt; meetings are scheduled each month to ensure this deadline is met.

b. All appropriate agencies will be invited to attend the meeting including the notifier, if appropriate. This may be in addition to those agencies that are established members of the SAR Sub-Group.

c. The Chair of the SAR Sub-Group meeting must be independent of the referring agency and the Local Authority where the adult is/was normally resident.

d. The information contained on the notification (SAR01) and collated initial chronologies will be considered by the SAR Sub-Group and a decision made using the TSAB SAR Policy, TSAB SAR Decision Support Guidance and the DH Care and Support Statutory Guidance, as to whether the case:

• Meets the criteria for a SAR
• Does not meet the criteria for a statutory SAR but another type of review (Discretionary) would be appropriate or, other action may be recommended such as a single agency review or the development of a Learning Briefing.
• The criteria are not met and no further action is to be taken

e. To ensure a proportionate recommendation is reached the SAR Sub-Group will also take into account:

• Whether any other Statutory Review processes are taking place, for example, Domestic Homicide Reviews (DHR), Child Safeguarding Practice Reviews (CSPR), see Section 12
• Whether any other significant processes are taking place, for example, Police Investigation, Complaint, Coroner’s Inquest, and
• What potential impact a SAR may have on such investigations or proceedings including whether a SAR should not start or be delayed until other proceedings have been completed
• If there needs to be a delay in the commencement of a SAR, then the SAR Sub-Group Chair will ensure that any learning at this stage of the process is identified and shared with relevant parties.

f. The SAR Recommendation Summary Form (SAR03) will be completed to record the discussions held at the meeting and to outline the recommendation to the Independent Chair.

g. If there is any dissent from a SAR Sub-Group member that cannot be resolved within the meeting, this will be recorded on the SAR03 form.

h. Once a recommendation has been determined this will not be shared outside of the SAR Sub-Group until the TSAB Independent Chair has confirmed the final decision.

i. The TSAB Independent Chair will be advised of the recommendation in writing using the SAR03 form.

j. The final decision to conduct a SAR is the responsibility of the TSAB Independent Chair. The Chair may wish to seek peer challenge from another SAB Chair when considering this decision.

k. In the event of the TSAB Chair disagreeing with the recommendation further discussions will take place between the TSAB Chair and the SAR Sub-Group Chair to establish a way forward.

l. The referring agency/ person will be informed of the decision

m. Those agencies that provided a chronology will also be advised of the decision.

n. Discussions will be held on how to inform the adult and/or their representative if a SAR or discretionary review has been agreed. This will also be confirmed in writing along with the information leaflet (SAR04)