Procedure for Safeguarding Adult Reviews

Under section 44 of the Care Act 2014, A Safeguarding Adults Board (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:

1. 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
2. condition 1 or 2 is met

Condition 1 is met if:

1. the adult has died, and
2. 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)

Condition 2 is met if:

1. the adult is still alive, and
2. the SAB knows or suspects that the adult has experienced serious abuse or neglect.

A 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).

Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to:

1. identifying the lessons to be learnt from the adult's case, and
2. applying those lessons to future cases

Where the mandatory SAR criteria is met a SAR must be commissioned. A SAR will be led by an author who will be responsible for undertaking the review, developing the recommendations and writing the report. In most cases, this will be an independent author commissioned to undertake the SAR on behalf of the CYSAB. The Independent Chair will then consider how this is done and whether a full review needs to be undertaken if the learning has already been identified but not yet actioned. e.g. learning has been taken from a similar SAR, or consideration of thematic reviews.

Where referrals relate to individuals who have died or been seriously injured within the City of York area, but it is more appropriate for another area to conduct a review or another SAB, this will be considered by the independent Chair who will discuss the matter with the appropriate board Chair. The default position in the absence of agreement will be that the SAB where the death or injury occurred will be the commissioning board.

The CYSAB may also undertake a SAR in situations where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults and can include exploring examples of good practice. This will be actioned at the discretion of the SAR Decision Panel and with agreement by the CYSAB chair.

Following a significant event, active consideration should be made as to whether a referral for a SAR is required. To support this, organisations should consider including an appropriate trigger question on internal incident reporting, investigation and/or review templates, or have appropriate mechanisms in place to be able to readily identify scenarios that require referring into the SAR process.

It is important to note that the SAR notification process does not affect any internal review processes.

Section 45 of the Care Act 2014 establishes the importance of organisations sharing with the SAB information relating to the abuse or neglect of people with care and support needs. If the SAB requests relevant information from an organisation or person, then section 45 of the Act creates a legal duty for that body or person to share what they know with the SAB.

In the context of SARs, something 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 serious or significant harm as a result of the abuse or neglect