Lincolnshire Safeguarding Adults Board Annual Report

We will ensure that the learning from all our reviews and assurance activities is shared.  It will be embedded within partner agencies to reduce the risk of repeat incidents or causes of harm.

Safeguarding Adults Boards (SAB) have a statutory duty to undertake safeguarding adult reviews when:

"...an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult."

A SAR may be needed even if an adult has not died.  If the SAB knows or suspects that an adult has experienced serious abuse or neglect, they must arrange a SAR. 

The review aims to identify learning that can be used to improve outcomes for others.  The review is not to find fault and apportion blame.

The Significant Incident Review Group for Adults (SIRGA) is a subgroup of the LSAB.  Under the Care Act 2014 it is responsible for safeguarding adult reviews (SARs).

SIRGA manages the process of recommending and commissioning SARs.  They also ensure multi-agency partnerships and individual agencies have addressed recommendations and associated actions. Throughout 2022 and into 2023, the board has:

• Progressed one safeguarding adult review – SAR Anthony.  This review is expected to be completed and published by late Autumn 2023.  The group has worked together on all proposed recommendations, ensuring that key learning is cascaded in a timely way.
• Received and considered five significant incident notifications. When looked at further, they did not meet the criteria for a safeguarding adults review.  In two notifications, learning identified from single agency processes was presented and discussed at a subsequent SIRGA meeting.

All published reports, executive summaries and learning bulletins are on the LSAB website.

Ongoing SAR – Anthony

Lincolnshire Community Health Services NHS Trust made a referral in February 2022 following the death of a man in his sixties in hospital. The male was part of a family where there were complex dynamics.  He was believed to have a learning difficulty, and there were concerns about the conditions within his home, which he owned, and around self-neglect.

The notification was discussed at the SIRGA meeting, where it was decided that the criteria for a SAR had been met.

Information gathering from partners has taken place.  As the SAR has progressed, the group has worked together to:

• identify emerging themes and agreed recommendations
• ensure that key learning is cascaded in a timely way throughout the review process

The report has been written and is expected to be published in the late autumn of 2023.

What we learned

The learning that emerged from this review highlighted the importance of:

• identification and escalation of safeguarding concerns
• professional curiosity
• practitioners’ knowledge of executive functioning
• the multiagency response to self-neglect
• discharge planning

There was good practice identified in relation to:

• professional tenacity of professionals in ensuring Anthony received the care needed
• the practice of some professionals in undertaking assessments of capacity

What we have done

• learning has been taken forward through a reflective partnership event, applying the learning from the review to the self-neglect protocol
• the process of the review to date has been quality assured using the Lincolnshire SAR policy and toolkit, including SCIE quality markers

What we will do

• deliver a learning event to cascade the learning from this review and the wider body of knowledge of research and practice
• development of an “easy read” version of the report
• development of a learning bulletin
• reflect the learning from the review in the professional curiosity resource pack
• reflect the findings of the review of the Lincolnshire self-neglect strategy and our strategic plan
• share a range of learning materials around executive functioning

How we will know this has impacted on practice

• peer review and site visits as part of the new assurance framework will provide quantitative evaluation
• include patient stories that reflect the key areas of learning as a standing agenda item at SIRGA meetings to provide a qualitative evaluation
• scrutinise individual agency audit feedback

Learning from SARs – a thematic approach

Throughout 2020 and 2021, three notifications were submitted to SIRGA for consideration as a SAR.  Two were additionally submitted to the Lincolnshire Domestic Abuse Partnership (LDAP) for consideration for a domestic homicide review (DHR).

Although none of the cases met the statutory criteria for an SAR or DHR, similarities in cases were noted.  It was agreed that a joint thematic non-statutory review would be undertaken. The joint thematic review was completed in the period 2022 to 2023.

The learning

The learning emerging from this review highlighted the importance of:

• raising professional awareness of the completion of DASH risk assessments when professionals fail to engage service users
• considering whole households in assessment practice
• consideration of how disability may impact on engagement
• responding effectively to individuals with complex needs, including those who lack executive function capacity
• professional curiosity

What we have we done

• SAB has asked each agency for evidence of how the learning has been taken forward in relation to awareness raising related to DASH risk assessment and assessment practice.
• The learning through the thematic review has been developed into an action plan. There are agreed actions and their progress is monitored at each monthly SIRGA meeting.
• Based on the review, a learning bulletin has been developed and circulated across the partnership.
• SIRGA has developed a pool of learning and development material on executive functioning.
• LDAP has commissioned a “tool kit” which will:
  • support practitioners when working with domestic abuse and those living with dementia or cognitive impairments
  • be shared across the partnership

What more we will do

• develop a seven-minute briefing to promote the professional curiosity resource pack
• review the complex needs section in the policies and procedures

How we will know the learning has impacted on practice

• peer review and site visits as part of the new assurance framework will provide quantitative evaluation
• include patient stories that reflect the key areas of learning as a standing agenda item at the meetings

SAR recommendations

All SARs commissioned by the LSAB include recommendations from the independent reviewing author. These recommendations charge the LSAB and its partners with improving systems to try and prevent similar significant issues from occurring in the future.

SIRGA monitors the recommendations until they are completed, and the impact on the service users’ experience is assessed through the SAB assurance framework.

SARs in rapid time learning and development

The SARs in rapid time is a training programme funded by DHSC and delivered by SCIE.

The training focuses on a model for completing safeguarding adult reviews in rapid time.  It also offers a process and tools to support SABs in producing learning of practical value for ongoing improvement work. Several SAB and SIRGA members have attended the training.  The approach is included in the updated Lincolnshire safeguarding adults review policy and toolkit.

SAR quality markers

The SAR quality markers are a tool to support people involved in commissioning, conducting and quality-assuring SARs to know what good looks like. Covering the whole process, they provide a consistent and robust approach to SARs.

The quality markers are based on:

• statutory requirements
• established principles of effective reviews
• incident investigations
• practice experience
• ethical considerations

The SAR quality markers assume the principles of MSP, as well as the six principles of safeguarding that underpin all adult safeguarding work:

• empowerment
• prevention
• proportionate
• protection
• partnership
• accountable

These principles, therefore, permeate the quality markers explicitly and implicitly. The Lincolnshire safeguarding adults review policy and toolkit has been updated to reflect the revised SCIE quality markers.

Analysis of safeguarding adults reviews

This report was commissioned by the Care and Health Improvement Programme (CHIP).  It presents the findings of the first national thematic analysis of published and unpublished SARs in England since the implementation of section 44 of the Care Act 2014.

When published in 2021, LSAB conducted a benchmarking exercise against the report’s proposed sector-led improvement priorities. LSAB continues to use this resource to support the SAR process’s ongoing improvement.