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.

Inter-related investigations, reviews and other processes

There are a number of other processes, including criminal investigations and NHS Significant Adverse Event reviews, that could be running in parallel with a Significant Case Review [please see Annex 1] and this raises a number of issues including:

  • relationship of the Significant Case Review with other processes, such as criminal proceedings and Health Board reporting and reviewing frameworks
  • securing co-operation from all agencies, including relevant voluntary sector interests in relation to the release and sharing of information
  • minimising duplication through the integration and coordination of these processes wherever possible
  • ensuring a sufficient degree of rigour, transparency and objectivity

Depending on the case, there could be a number of processes which come into play which are driven by considerations wider than service failure or learning lessons across agencies. These can include a criminal investigation, report of a death to the Procurator Fiscal or a Fatal Accident Inquiry. In addition to this, agencies should ensure that the areas for improvement identified and shared learning are directed through the relevant clinical and care, or quality assurance, governance arrangements.

These processes may impact on whether a review can be easily progressed or concluded; criminal investigations always have primacy. To help establish what status a Significant Case Review should have relative to other formal investigations there should be on-going dialogue with Police Scotland, COPFS or others to determine how far and fast the Significant Case Review process can proceed in certain cases. Good local liaison arrangements are important. Issues to be considered include:

  • how to link processes
  • how to avoid witness contamination
  • how to avoid duplicate information being collected
  • whether to postpone a Significant Case Review until determination of a parallel proceeding

There could be cross-cutting issues, for example, gender based violence, human trafficking, problematic alcohol and drugs use or young people in transition from children's services. On occasion complex interconnected events may require consideration of a joint Significant Case Review.

Processes can, and do, run in tandem, and the basic principles to follow are: check if there are other processes going on from the start; ensure good communication with each other; and ensure the relevant information is shared with the right parties. Above and beyond this, the priority is that the adult is, and remains, safe, regardless of other ongoing investigations (including criminal investigations). Consideration should be given to the safety of other adults who could also be at risk of harm. The rights of staff or others, who are under investigation, but have not been charged or found guilty, is another factor to be taken into account.



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