Serious case reviews and case reviews take place where a child or an adult at risk has been seriously harmed or has died or where abuse appears to have been engrained within the practices. They are conducted by the local authority (Knows as a Safeguarding Adult Board SAB) and are responsible for safeguarding the area in which they took place, outcomes of these are usually published in the press. They can lead to change in local and/or national policy.

Where there is a concern about a serious case the government can set up a formal inquiry to investigate what went wrong and to recommend what needs to change. These are followed by a formal report. Serious case reviews, case reviews and inquiries do not decide who was guilty but they look at what went wrong and how to prevent it from happening again. Decisions about who was responsible for the death or injury/who was guilty are made through the courts.

Some of the factors featured in reports from serious case reviews (now SARs) are:

• Poor or a lack of communication between services, including not sharing important information
• Ineffective partnership working between services
• Those receiving care and support or their families and friends not being involved in decisions made about their care
• A failure to identify signs of abuse
• Lack of management support or presence
• Limited learning and development opportunities for workers
• Poor staff recruitment processes

Examples of serious case reviews involving adults:

• Serious Case Review – Winterbourne View (2013 South Gloucestershire Council). This involved the psychological and physical abuse of patients in a private hospital for people with learning disabilities. When the scandal emerged the government responded by publishing a series of guidance documents which aim to prevent the same situation arising elsewhere.
• Serious Case Review – – Steven Hoskin (2007 Cornwall County Council). A man who had learning difficulties living on his own is St. Austell who was murdered by people in the community. The police, social services and health failed to respond to his requests for help and him alerting them to the dangers he was facing.
• Serious Case Review – Gemma Hayter (2010 Warwickshire Council) Gemma was beaten to death in August 2010 at the age of 27, agencies missed 23 opportunities to initiate safeguarding procedures or otherwise intervene to improve the quality of life.
• A highly significant recently completed inquiry led to the Francis Report which focused on the abuses which took place at the Mid-Staffordshire NHS Foundation Trust, published in February 2013. www.nhsemployers.org/The-Francis-Inquiry/Pages/Francis.aspx.

Use to answer question 10.1i of the Care Certificate