Carrying out a Significant Case Review
A potentially complex set of activities (see Annex 1) may be triggered by a significant case. It is important that local services do not interfere in or contaminate that activity, especially in relation to evidence gathering where there is, or might be, a criminal investigation - whether of staff involved in a case or a third party. The key requirement is to maintain good ongoing dialogue with the COPFS and/or Police Scotland to ascertain where they are in their considerations and agree what can be progressed in the Significant Case Review. Efforts should be made to minimise duplication and ensure, as far as is practicable, that the various processes are complementary albeit their purpose could be somewhat different. These inter-related processes are less likely to take place if a significant case does not involve a death. During the course of a Significant Case Review any evidence of criminal acts or civil negligence relating to the case which comes to the attention of the Lead Reviewer (see below) or Review Team should be reported to the Police.
If not already the case, Adult Protection Committees should seek to ensure they have a named contact in the Procurator Fiscal's office to be able to pursue such ongoing dialogue as is required to meet the objectives of each type of activity.
There will also be agency-specific work that is routinely undertaken, particularly on the death of an adult at risk of harm, for example, when this occurs in hospital or is unexpected such as in the case of sudden unexpected deaths. It will be important that any Significant Case Review is coordinated to dovetail with such work to avoid duplication of effort and unnecessary further review.
The Adult Protection Committee should seek to inform all those who will contribute and who have a legitimate interest in the Significant Case Review at each stage of the process. It may be useful to have a single point of contact and keep a log of who requests information. As each significant case will be different, the names and roles of those with an interest might vary. Throughout the process, consideration should be given as to whether there is anyone else who should be informed, or how much information should be offered to different parties on the Significant Case Review. It is important to be clear who needs to be aware of the review, what information they need, and when and how this will be provided. Each Adult Protection Committee should agree with local agencies who the contact points should be and their role in the process, i.e. whether it is communication for information or decision-making.
3) The Lead Reviewer/s
The Adult Protection Committee will need to consider whether a significant case review should be led internally or externally or with some external overview. Adult Protection Committees must ensure that the Lead Reviewer and the review team, between them, have the necessary skills and competencies to undertake a Significant Case Review. These skills will differ according to the circumstances of each case and the agreed role of the review team. Annex 4 provides a 'person specification' list for a Lead Reviewer.
The Adult Protection Committee may decide to appoint an internal lead reviewer or two reviewers if the circumstances of the case, based on the evidence of the Initial Case Review, suggest that any recommendations are likely to have mainly local impact. In the case of an internal review the team would probably be drawn mainly from within the Adult Protection Committee's member agencies but it should always consider using external expertise to provide impartial advice or comment in the form of a consultant, professional advisor or critical friend.
The Adult Protection Committee may decide to commission an external lead reviewer if:
- there are likely to be national as well as local recommendations
- local recommendations are likely to be multi-agency rather than single agency
- the case is high profile, or is likely to attract media attention
- Councillors, MSPs or other elected members have voiced concerns about local services
- the Adult Protection Committee is facing multiple reviews
- the adult's family/carers or significant others have expressed concerns about the actions of the agencies
Where an external review is commissioned, the Significant Case Review continues to be owned by the Adult Protection Committee.
The Adult Protection Committee should agree any formal contractual arrangements that may be required. They should consider which agencies will enter into the contract and ensure that individuals have professional indemnity cover. Consideration should be given to involve legal services in the drawing up of formal contracts that incorporate areas such as timescales, fees and confidentially.
Their contract should also include explicit instructions on the access to, storage of, transport of, transmission of and disposal of sensitive personal information as required by the Data Protection Act. As the independent chair is acting on the instructions of the Adult Protection Committee (representing the Chief Officer Group or equivalent) they are acting as a Data Processor and not a Data Controller for the purpose of the Significant Case Review and do not require to be registered with Information Commissioner's Office.
Regardless of whether the Lead Reviewer is internal or external the Adult Protection Committee will wish to set out clear expectations in respect of timescales, key milestones in the process and for completion of reports.
4) The Review Team
The Adult Protection Committee should ensure there is sufficient multi-agency representation on the review team in order to reflect the case in question. It is important to assemble a mixed team to support the Lead Reviewer so that key agencies feel confident their specialist issues are understood. The different perspectives of a mixed review team can add to the depth of enquiry. Any training or information requirements for the team should be considered. Consideration should also be given to the knowledge, skills and experience required in the review team.
The review team should be agreed, and their roles and responsibilities, including who will undertake tasks such as file reading and interviews, tasks, and how disputes will be resolved. No-one should be involved in a review if they were directly involved in the case in a professional capacity.
For any review team, it is important to establish whom the key contacts are in all the agencies involved. These could be designated Significant Case Review contacts who can also advise on, and broker access to, relevant practitioners and information, provide any agency information that may be relevant (protocols/guidance) and generally act as a liaison point. In addition consideration should be given to who will make the links with relevant parties beyond the main statutory agencies. The team will also need to gather relevant evidence from a wide variety of sources and be prepared to negotiate if information is not forthcoming.
The Adult Protection Committees will want to consider ensure that the Review Team has the following:
- a broad knowledge of health and social care, criminal justice and other relevant areas, such as housing
- recent operational experience at a senior level of health and social care or criminal justice
- investigation skills
- analytical and evaluation skills
- report writing skills
- an understanding of different methodologies and why one may be more appropriate than another in particular circumstances
- ability to make sound judgments on information collected
- ability to critically analyse all factors that contributed to the significant case and the wider impacts for practice and service delivery where appropriate
- ability to liaise with other bodies and establish a good working relationship
- demonstrate sensitivity to national and local level issues
- appreciation of the need to be clear about the difference between a Significant Case Review's remit and task as opposed to other ongoing proceedings relating to that case (for example, a criminal investigation)
- where required, specialist input
Adult Protection Committees should always consider and agree the methodology to be used in undertaking the Significant Case Review. This may vary according to the case and agreed responsibilities of the team.
Reviewers are expected to be able to use an established and evidence-based scrutiny methodology; for example, systems approach, root cause analysis or the Social Care Institute for Excellence (SCIE) 'Learning Together' model. For those conducting a Significant Case Review using this methodology, there will be no specific recommendations but findings and issues for the Adult Protection Committee to consider. The Welsh Government has developed a tiered approach. This has a multi-agency professional forum for cases with a shorter process and formal review processes.
6) Chronology or timeline
The Adult Protection Committee will wish to ensure that a multi-agency chronology or timeline of significant events and contacts is prepared (this may already have been prepared as part of the Initial Case Review process) and circulated to agencies and professionals to check for accuracy.
Depending on the comprehensiveness of the information gathered at the Initial Case Review stage it may be possible for the Adult Protection Committee, or specially convened sub-group, to agree the remit of the full Significant Case Review at or following the initial meeting. If there are areas that require further clarification the Adult Protection Committee, or sub-group, may request that agencies undertake key tasks and report back within an agreed timeframe.
In the case of an externally led review the remit of the review and the key question(s) to be addressed should be agreed in writing by the Adult Protection Committee and the External Lead Reviewer.
The clearer the remit the easier it will be to manage the expectations of those involved in contributing to the Significant Case Review, and the wider audience, in the outcome of the review. It is recognised that the degree of complexity and/or which people to involve might not become clear until some initial work has been undertaken, especially in the case of an external Significant Case Review. Consequently, the remit may need to be reviewed at a later stage. If changes are made, they should be agreed and appropriately documented by the Adult Protection Committee or sub-group.
A deadline for production of reports, which takes account of the circumstances and context of the case, should be included within the remit. Where deadlines have to be extended, for example in circumstances where other proceedings intervene, this should be recorded and a new deadline agreed by the Adult Protection Committee, or sub-group.
The Lead Reviewer (internal or external) must be briefed by the Convener of the Adult Protection Committee (or person with designated responsibility). The Lead Reviewer must be given access to the initial reports and chronology prepared by agencies for the Initial Case Review, to assist in identifying which agencies need to attend the Significant Case Review meetings.
The written remit of the Review should be agreed by the Adult Protection Committee. It can be reviewed throughout the process, but changes must be agreed with the Adult Protection Committee. The review team should report on progress made to the Adult Protection Committee or Significant Case Review sub group.
The remit should:
- clarify roles and responsibilities across agencies
- set a timeframe to be covered by the review
- agree a timeline for conducting the review
- be clear and deliverable
A review may reveal staff actions or inactions which are of sufficient seriousness that they need to be brought to the attention of the employer. The review team has a duty to do this, irrespective of the Significant Case Review process.
8) Support for staff involved in a review
During the review process staff should be informed and supported by their managers. There may be parallel but distinct processes running which staff are involved in (e.g. disciplinary proceedings) as well as the Significant Case Review so sensitive handling is important. The impact on staff and the implications for human resources, regulators and others requires careful consideration.
Each organisation should have its own procedures in place for supporting staff, but the following should always be considered:
- the health and well-being of staff involved
- provision of personal, welfare, counselling or trauma-informed support
- how to engage with staff, keep people informed of the process in an open and transparent way, and provide protected feedback
- the need for legal/professional guidance and support
- time to prepare for discussions and interviews and for follow up and clarity about how the information provided will be used
This framework should be given to staff involved in a review, together with a copy of the local operational protocols in place in their Adult Protection Committee area to support this framework. Once the review has been completed staff involved in the case should be given a debrief on the review and the findings before the report is published. Adult Protection Committees will also wish to consider what mechanism will be used to enable contributors to confirm the accuracy of what is recorded as it is drafted for the interim and/or final report.
9) Involvement of the adult and their family/carers
The family/carers of the adult at risk should be kept informed of the various stages of the review as well as the outcomes where appropriate. There will be occasions where the family/carers could be subject to investigation or have otherwise triggered the Significant Case Review. In these cases, information may need to be restricted. Close collaboration with Police Scotland, the Procurator Fiscal, and any other relevant agency will be vital.
There may also be cases where families/carers are considering taking legal action against an agency or agencies that are the subject of the Significant Case Review. Individual agencies should ensure that their complaints procedures are made available to the family/carer at the outset of their involvement, and throughout any Significant Case Review investigation, as deemed necessary and appropriate. This is not the responsibility of the Adult Protection Committee or of the review team.
Significant Case Review reports should include information about whether or not the adult and their family/carer were informed and involved. If not, reports should record a reason. If they were involved, reports should record the nature of the involvement and document how their views have been represented. Diversity issues should be considered and adequate support should be provided to ensure that the adult and family members/carers are able to participate.
Care should be taken about where and when an adult, or their family/carers, are interviewed, and if any special measures are needed to support this (for example, the use of advocacy or interpreter services, with particular care given to those with impaired communication). In particular if there are, or are likely to be, criminal proceedings or if there is, or likely to be a fatal accident inquiry, the review team must consult with the local Crown Office and Procurator Fiscal Service and police prior to any interviews.
It may also be useful to assign a member of staff to liaise with the adult or the family/carer throughout the review. This person should not be involved in the Significant Case Review process or a member of the review team. The person carrying out this liaison role should be fully aware of the sensitivities and background of the case. This person's role could include advising the family of the intention to carry out a Significant Case Review and making arrangements to interview the adult, family/carers or other significant adults involved. Any briefing would normally be an oral discussion.
Depending on the particular case and sensitivities, consideration should be given to arrangements for feedback to the family. This may also include how they can input into checking the accuracy of what is recorded in the interim and/or final report.
Resources should be considered when commissioning a Significant Case Review. It is for each Convener to negotiate with the Chief Officers' Group or equivalent to secure appropriate resources in advance. Support, advocacy and communication needs should be considered.
11) The Report
A Significant Case Review Report should seek to:
- set out the facts on the circumstances leading to and surrounding the death/serious harm of the adult (it is acknowledged that this may be difficult if there are parallel inquiries taking place, e.g. a criminal investigation);
- examine the role of all agencies involved in providing care, support and protection services (this may be achieved by establishing a chronology of agencies' and professionals' significant events and contacts), and analyse and assess the circumstances drawing out the implications and issues
- explore any key practice issues and the reasons for these
- establish the areas for improvement and lessons to be shared, about the way in which agencies work individually and collectively to protect adults at risk of harm
- consider how lessons are to be acted on and what is expected to change as a result. Consider whether there are gaps in the system and whether services should be reviewed or developed to address those gaps. Consider whether specific recommendations are required.
It is important to have a degree of consistency in the structure and content of Significant Case Review reports. This will make it easier for people to identify and use the findings or recommendations and for read-across to other reports to be made. The report should, therefore, include the areas outlined in Annex 5.
Adult Protection Committees should consider the necessary arrangements for correcting factual errors or misunderstandings in drafts of the report.
In agreeing the final report, whether internally or externally commissioned, the following steps apply:
1. The Lead Reviewer will present the final report (and executive summary) to the Significant Case Review team
2. The Review team will send the final report to the Adult Protection Committee Convener for presentation to the Adult Protection Committee.
3. The Adult Protection Committee will then send the final report to the Chief Officers' Group.
4. The Adult Protection Convener may ask the Lead Reviewer to present the report to the Adult Protection Committee or the Chief Officers' Group.
5. The content and acceptance of the final report (as well as considerations regarding publication, media handling as outlined below) will be agreed between the Adult Protection Committee and Chief Officers' Group through the stepped process above.
12) Freedom of information and data protection
The Adult Protection Committee should ensure that the review team and Lead Reviewer take account of the requirements of the Freedom of Information Act 2002 and Data Protection Act 2018 in both the conduct and reporting of the review. Annex 6 contains an extract from a Significant Case Review which may be helpful in considering the report structure and content in respect of the Data Protection Act 2018. Healthcare Improvement Scotland have developed guidance on sharing information. When an independent/external lead reviewer is appointed, NHS will wish to seek Caldicott approval in respect of access to any patient files where this is required by the lead reviewer as part of the review process. This should be done as early as possible.
Arrangements should be put in place for secure storage and filing of confidential information and files. These arrangements should also include retention schedules and processes for destruction of the information when it is no longer necessary to hold. These details can be included in data sharing agreement.
Adult Protection Committees should timeously agree a local dissemination approach which ensures the spread of any identified good practice as well as learning, particularly to front line staff.
Adult Protection Committees may also want to consider sharing reports with interested parties such as the Scottish Adult Support and Protection Conveners' Group and Social Work Scotland Adult Protection Practice Network.
The Care Inspectorate, on behalf of Scottish Government, acts as a central collation point for all Initial Case Review decisions and Significant Case Reviews completed across Scotland at the point at which they are concluded. By receiving and reviewing all Significant Case Reviews, the Care Inspectorate can better engage with Adult Protection Committees and Chief Officers to support continuous improvement locally and to disseminate common themes to support national learning.
Whether to publish the full report or just the executive summary is a decision which should be made by the Adult Protection Committee and approved by the Chief Officers' Group or equivalent. In making this decision consideration should be given to the necessity to restore public confidence, the protections within the Data Protection Act 2018 and balancing interests in terms of the right to respect for private and family life in terms of Article 8 of the European Convention of Human Rights. Where the full report is not being published, the summary should give an explanation of the redaction that has been required. See Annex 6 for an example.
The first responsibility of the Adult Protection Committee is to report to the Chief Officers Group or equivalent. But the Adult Protection Committee has wider responsibilities and must consider the wider reporting requirements and distribution of the Report/Executive Summary. A list of potential organisations and persons to whom the Report/Executive summary can be sent is contained at Annex 7 but it is always up to the Adult Protection Committee in consultation with the Chief Officers Group or equivalent to decide this in each individual case.
It is imperative that the adult's right to privacy and the adult's right to be protected is at the forefront of all decisions and communication relating to publication of a Significant Case Review report.
Family/carers and/or other significant adults in the adult's life should receive a copy of any report in advance of publication except if they are subject to any criminal proceedings in respect of the case.
Publication of the report may require to be delayed until the conclusion of criminal or FAI proceedings. Where criminal or FAI proceedings are ongoing the publication of any report should always be discussed and agreed with COPFS.
Other considerations for the Adult Protection Committee include the following.
- whether an oral briefing for relevant parties in advance of publication is required. This is particularly the case where there is likely to be interest in the case amongst the wider public and may avoid misrepresentation
- how publishing the Significant Case Review report will support learning
- whether the Significant Case Review report is set within the wider context of health and social care
- whether all parties have been informed and their views taken into account (adult, family and staff)
- has the integrity of staff been respected and duty of care been considered
15) Media handling
The media can help promote more effective prevention and intervention to protect adults at risk of harm by raising public awareness of the circumstances which can contribute to harm and what members of the community can do to mitigate these risks.
Where there is engagement with the media, the communications strategy should include a media handling plan. Most agencies will have communications officers for the agency and any protocols/handling issues should be developed in conjunction with them. Before the report is in the public domain it should be agreed who will link with the media on behalf of Chief Officers/the Adult Protection Committee, brief the relevant Communications Officer(s) and approve the wording of any quotes. No information relating to a Significant Case Review should be released to the press unless it has been approved by Chief Officers/Adult Protection Committee.
Communication with the media should focus on learning and highlight that most adults at risk of harm are protected. It is important to add an element of calm and focus and not to add to any sense of alarm or confusion and Adult Protection Committees should proactively offer interviews to the media where this supports their strategic objectives e.g. of raising awareness of the process of Significant Case Reviews or about the role of Adult Protection Committees.
Once the report on the Significant Case Review is published and in the public domain a high-level spokesperson, where possible, should respond to media requests
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