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.

Annex 5: Exemplar Significant Case Review Report

For those conducting a Significant Case Review using the SCIE 'Learning Together' Methodology, there will be no specific Recommendations but Findings and Issues for the Adult Protection Committee to consider

Core Data - Adult

Adult's Identifier
Age of adult
Sexual Orientation
Health needs (including mental health and /or learning difficulties
Living circumstances prior to incident
Position in family/ number of siblings
Nature of injury/cause of death
Legal status of adult
Agencies/Services involved

Family/carer factors (if applicable)

Mental health issues
Health needs (including mental health and/or learning difficulties)
Substance use (if applicable)
Convictions (if applicable)
Problems in childhood (if applicable)
Domestic abuse (if applicable)
Add antisocial behaviour (if applicable)
Marital/relationship status eg co-habitation
Living circumstances
Agencies/Services involved

Environmental Factors

Financial problems
Support from extended family/ community


This includes the circumstances that led to the review, the purpose and focus of the review, the periods considered and agencies involved, the extent of the family's/carers' involvement. Note how long the report has taken and reasons for any delays.

The facts

This includes the family background and circumstances, and agency involvement. A chronology or timeline of significant events, (including when the adult was seen and by whom and whether the adult's views were sought) is also included. Where appropriate, the chronology may be presented in a number of distinct phases and supplemented by a written account of what happened during each phase. A genogram (a type of family tree) may be a useful format to map out key relevant person, and families. In the reviewing of the case, a full chronology will be required but for the purpose of the report, the primary aim at this stage is to highlight areas of practice or events that are considered by the review to be particularly relevant, not to provide an overly detailed account of events. As such the full chronology should not be included within the body of the report. Details of all significant others in the adult's life should also be included.


This section critically assesses the key circumstances of the case, the interventions offered, decisions made etc. For example, were the responses appropriate, were key decisions justifiable, was the relevant information sought or considered, were there early, effective and appropriate interventions? Where the family and adult's circumstances sufficiently assessed? It should be remembered that the review is taking place with the benefit of hindsight and the analysis should consider the actions of services within the context of the circumstances of the time.

Key issues

Following on from the analysis and depending on the circumstances of the case, the review should clearly identify the key areas that impacted on the adult and agency responses and then explore these further to understand how they came about. This section should assist readers to understand the "why" of what happened and a level of analysis (for example, root cause) should be applied. It would be helpful to explore key areas within a framework of cause and effect factors - for example, resourcing, organisational culture, training, policies etc.

Learning points

This section highlights the key learning points from the review - again the focus here should not be on 'what happened', but the reasons why it happened as it will be these areas that services and organisations can actively take forward and address. This section should also actively address strengths and good practice identified as well as the learning that has taken place since the case, any changes in practice and policy that have been implemented and the outcome of changes.

Recommendations or if using SCIE model findings and Issues

Executive Summary

This provides a brief, possibly anonymised, account of the circumstances of the case and agency involvement. Chronologies should not be included. Analysis of the key events has to be sufficient to allow a context for the identification of the key issues and learning points but a balance has to be struck to ensure confidentiality issues are respected. The learning points, recommendations and action points should be replicated in full.


These include, if not already within the body of the report:-

  • Review Team membership
  • Remit/terms of reference
  • Chronology
  • Files accessed/relevant documents
  • People interviewed (their professional role or relationship to the adult)



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