Adult protection significant case reviews: interim framework

Framework to support a consistent approach to conducting adult protection significant case reviews and improve the dissemination and application of learning both locally and nationally. This framework is for all partners.

The purpose of a Significant Case Review

An Adult Support and Protection Significant Case Review is a means for public bodies and office holders, with responsibilities relating to the support and protection of adults at risk, to learn lessons from considering the circumstances where an adult at risk has died, or been significantly harmed. It is carried out by an Adult Protection Committee under its functions of keeping procedures and practices under review, giving information and advice to public bodies and helping or encouraging the improvement of skills and knowledge of employees of public bodies as set out in section 42 (1) of 'the Act'.

A significant case review should seek to:

  • understand the full circumstances of the death/serious harm of the adult (where parallel processes like a criminal investigation are in place, it may not be possible to gather and report full information);
  • examine and assess the role of all relevant services, relating both to the adult and also, as appropriate, to relatives, carers or others who may be connected to the incident or events which led to the need for the review;
  • explore any key practice issues and why they might have arisen;
  • establish whether there are areas for improvement and lessons to be shared, about the way in which agencies work individually and collectively to protect adults at risk;
  • identify areas for development, how they are to be acted on and what is expected to change as a result;
  • consider whether there are issues with the system and whether services should be reviewed or developed to address these; and
  • establish findings which will allow the Adult Protection Committee to consider what recommendations need to be made to improve the quality of services.

The overarching objectives of review are to:

  • keep under review the procedures and practices of the public bodies and office-holders required to cooperate with councils to which section 43 (3) of 'the Act' applies which relate to the safeguarding of adults at risk present in the council's area
  • give information or advice, or make proposals, to any public body and office-holder to which section 43 (3) of 'the Act' applies on the exercise of functions which relate to the safeguarding of adults at risk present in the council's area
  • share learning with relevant agencies and make recommendations for action
  • consider how any recommended actions and learning will be implemented
  • address the accountability, both of the agency/agencies and the occupational groups involved
  • increase public confidence in public services, providing a level of assurance about how those services acted in relation to a significant case about an adult at risk of harm.

This framework supports the achievement of these objectives by helping those responsible for reviews to:

  • undertake them at a level which is necessary, reasonable and proportionate
  • adopt a consistent, transparent and structured approach
  • identify the skills, experience and knowledge that are needed for the review process and consider how these might be obtained
  • address the needs of the many individuals and agencies who may have a legitimate interest in the process and outcome

This framework sets out:

  • the criteria for identifying whether a case is significant
  • the procedure for undertaking an Initial Case Review
  • the process for conducting a Significant Case Review including reporting mechanisms and dissemination of learning
  • tools to support the process of conducting an Initial or Significant Case Review



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