Learning from Significant Case Reviews
The Adult Protection Committee should consider how the analysis and recommendations from a Significant Case Review can best inform learning and practice. Types of learning that can be shared, exchanged or disseminated from significant case reviews include:
- considering the key challenges of the review and how these were, or could be, overcome
- reflecting on the issues identified and barriers to change, and the action that has been undertaken, or will have to be
- measuring the impact that a Significant Case Review has had
Capturing learning in relation to the process, output and follow-through of conducting significant case reviews could be achieved in different ways:
- internal/external quality assurance to appraise the process
- practice exchange/communities of expertise to share experiences, perspectives and skills
- research to critically appraise/analyse the strengths and limitations of arrangements used or to draw out messages for practice, policy and research
The Adult Protection Committee should produce a summary of cases considered by them over the course of the year and introduce these into the learning cycle, whether the decision was to undertake a Significant Case Review or not. Adult Protection Committees will determine the urgency for action planning and implementation within the learning cycle according to the significance of the issues raised.
After some Significant Case Reviews it may be necessary for other Adult Protection Committees to review their own guidance and procedures in light of the findings and recommendations. This could be facilitated through the existing groups or by specially convened meetings depending on the need for urgency.
Some recommendations from reviews may have implications for a range of bodies, and may need to be shared with agencies named in the Adult Support and Protection (Scotland) Act 2007, and other relevant bodies who have an interest in the circumstances of the case.
Significant Case Reviews are one source of information that can contribute to an agenda for learning and for practice and policy development. Other sources include the information generated through research and evaluation, inspection and audit and organisational knowledge (i.e. the understanding and awareness that exists among the staff within organisations). Together, these can provide a map of critical issues for practice. Each also represents an opportunity to identify good practice that can be shared. Areas to consider include:
- Adult Protection Committees could report on findings from their Significant Case Reviews in their biennial reports, where published, or within their Adult Protection Committee improvement plan (or whatever report/format Adult Protection Committees consider appropriate)
- brokering of practice expertise in undertaking and implementing Significant Case Reviews
- active dissemination (i.e. presentation and discussion) of findings from quality assurance and research exercises through conferences (on Significant Case Reviews or on themes emerging from Significant Case Reviews), seminars and existing meetings (e.g. Scottish Adult Support and Protection Conveners Group, National Adult Support and Protection Learning and Development Network; local Adult Protection Committees; single-agency forums)
- dissemination (i.e. circulation) of findings from quality assurance and research exercises
The Care Inspectorate will support practice improvement as a result of national learning identified by Significant Case Reviews by holding learning events and by exploring the development of mechanisms to support better sharing of learning from Significant Case Reviews across the country.
The Care Inspectorate will undertake a retrospective review of Significant Case Reviews conducted between a period to be agreed with Scottish Government to identify national learning and support improvement in relation to both practice in implementing adult support and protection legislation and processes and arrangements for reviewing significant incidents through the Significant Case Review mechanism.
The Care Inspectorate will conduct a regular review of the Significant Case Reviews completed in Scotland, and, report nationally on the key learning points for the benefit of relevant services across Scotland and the Scottish Government.