Last updated: 27.01.20

Safeguarding Adults: What is a Significant Case Review (SCR)?

When it comes to safeguarding adults, reviews are carried out throughout the UK in order to understand and analyse cases where abuse or neglect is known or suspected. Each region has its own name for its reviews – Significant Case Reviews are relevant to Scotland. Please select another region to find out about its type of review: England, Northern Ireland and Wales.


Adult safeguarding and protection policies are underpinned by the Adult Support and Protection (Scotland) Act 2007. Effective multi-agency working supporting cohesive and effective partnership working is positioned at the heart of the Act.

Adult Protection Committees set the direction for multi-agency working, contributing to effective safeguarding policy. The Code of Practice is aligned to the Adult Support and Protection (Scotland) Act 2007, providing clear lines of responsibilities and duties for the various agencies involved in adult safeguarding. However, it has been noted that the Scottish Government has seemingly prioritised child protection over adult protection, contributing to a lack of clear national direction and policy improvement.

Here we provide an overview of current practice, focusing on responsibilities for Significant Case Reviews (SCRs) and outlining the direction of the work Scotland is engaged in. Although policy development and the implementation of SCRs to drive change in Scotland has lacked attention, examples of high-profile Serious Case Reviews drawn from the UK will demonstrate the importance of reviews and their implications for improvement in adult safeguarding practice.

Adult Protection Committees (APCs)

Section 42 of the Adult Support and Protection (Scotland) Act 2007 (ASPSA, 2007) requires each council to establish an Adult Protection Committee (APC). It is a multi-agency entity, comprising representatives of the council, relevant NHS Scotland Board (in local area), the police and other organisations involved in adult protection.

APCs play a central role in overseeing adult protection in their respective areas. Their duties include:

  • Reviewing adult protection practices
  • Improving co-operation
  • Improving skills and knowledge
  • Providing information and advice
  • Promoting good communication
  • Evaluating the effectiveness of adult safeguarding arrangements in their local area
  • Every two years, Adult Protection Committees are required to submit a report to Scottish ministers.

Understanding Significant Case Reviews (SCRs)

A SCR is a multi-agency process for establishing the facts of, and learning lessons from, situations where an adult has died or been significantly harmed. Adult Protection Committees report findings to the Scottish Government to encourage and build on national safeguarding policy.

The aims and objectives of SCRs are to:

  • Establish if there are lessons to be learned about how to improve child protection, to ensure they are able to access the support they need in the future.
  • Learn where failures have occurred to improve services and recognise good practice.
  • Make recommendations for action if required, to support improvements.
  • Consider how any findings, recommended actions and learning can be implemented to support effective action.
  • Support accountability when things go wrong.
  • Increase confidence in public sector services by identifying gaps in provision and developing action plans to resolve this.
  • Identify when cases may be appropriate on a national basis to extend learning and development.

Questions assisting an effective SCR

What happened? Overview of the case to establish the facts.

What could have been done to prevent abuse and/or neglect? What actions could’ve been taken to stop the abuse from happening?

Is there typicality in the contextual factors and the responses of agencies? Are there similar challenges, or difficulties within agencies that could have contributed to the abuse and/or neglect?

What changes to the way in which agencies operate could help to prevent abuse/neglect? Identifying actions that could improve child safeguarding procedures to reduce the risk of harm to children and young people.

Have agencies changed their practices as a result of this learning? What changes in organisations have been made to support improvement in adult safeguarding practice?

Previous Safeguarding Adults Reviews and learning

Lessons learned from previous high-profile Serious Case Reviews () in England have contributed to the development of current safeguarding practice in Scotland. 

The following Serious Case Reviews were high profile, receiving national attention and can be considered key cornerstones to the improvements and development of adult safeguarding practice in Scotland. Select each title for more information.

Winterbourne View

Orchid View

Steven Hoskin