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Safeguarding adults - serious case reviews

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The Association of Directors of Social Services in their document ‘Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services’ described the overriding reasons for holding a review as being to learn from past experience, improve future practice and multi‐agency working. There is currently no statutory duty to conduct a Serious Case Review, however, reviews will become statutory when the Care Bill becomes law (expected to be in early 2015). The Surrey Safeguarding Adults Board has been in existence for over ten years and during that time has chosen to undertake Serious Case Reviews.

The Board has a Serious Case Review Protocol that identifies three purposes to be fulfilled by a Serious Case Review:

  • To establish whether there are lessons to be learned from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults at risk.
  • To establish what those lessons are, how they will be acted upon and what is expected to change as a result.
  • To improve inter-agency working and better safeguarding of adults at risk including the review of procedures where there may have been failures.

Serious Case Reviews are not inquiries into how an adult died or suffered injury or who is culpable.

When the Board has published a Serious Case Review, the Board’s Business Management Group will identify actions to address the issues highlighted in the Review and the recommendations made. The implementation of the action plans will be monitored and reviewed by the Business Management Group.

The Board has a protocol for the conduct of Serious Case Reviews. This can be downloaded from the link at the end of this page.

Files available to download

Page information

  • Updated: 21 May 2013
  • Elizabeth Butcher
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