Last updated: 27.01.20

Safeguarding Adults: What is a Serious Case Review?

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 – Serious Case Reviews are relevant to Northern Ireland. Please select another region to find out about its type of review: England, Scotland and Wales.

The Current Picture

Northern Ireland is currently developing and improving its adult safeguarding approaches and policies to align them to current child protection arrangements. Currently there is no specific legislation covering adult safeguarding, rather adult safeguarding rests on the interpretation of the 2015 policy ‘Adult safeguarding prevention and protection in partnership’. This has contributed fragmented and inconsistent responses in adult safeguarding practice.

In 2018, the first investigation into abuse at Dunmurry Manor Care Home was completed by the Commissioner for Older People in Northern Ireland (‘Home Truths’) and an Independent Review by the Department for Health of adult safeguarding systems in relation to abuse at Dunmurry. There is much to be celebrated, yet there is more work to do and the full role of the Northern Ireland Adult Safeguarding Partnership (NIASP) and respective Local Adult Safeguarding Partnerships (LASPs) is likely to develop further over time.

This module will provide an overview of current practice, focusing on responsibilities for SCRs and outlining the direction of the work Northern Ireland is engaged in. SCRs drawn from the UK will demonstrate the importance of reviews and their implications for improvement in adult safeguarding practice.

Northern Ireland Safeguarding Partnership (NIASP)

It is the role of the Northern Ireland Safeguarding Partnership (NIASP) to undertake a Serious Case Review when an adult has died, or experienced significant harm as the result of abuse and neglect.

SCRs are underpinned by the policy document ‘Adult Safeguarding Prevention and Protection in Partnership’ (2015); there is currently no legislative framework.

The purpose of an SCR is to: 

  • Establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and organisations work together to safeguard vulnerable adults.
  • Review the effectiveness of procedures.
  • Inform and improve local inter-agency and/or inter-disciplinary practice and working together to better safeguard adults.
  • Improve practice by acting on learning and emerging best practice and making sure that the lessons learned are clearly communicated in a timely fashion, understood, and appropriate action is taken within agreed timeframes.
  • Prepare or commission an overview report which brings together and analyses the findings of the various reports from organisations in order to make recommendations for future action.

When is an SCR is conducted?

An SCR is required where a vulnerable adult:

  • Dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in the death.
  • Sustains a potentially life-threatening injury through abuse, including sexual abuse, or neglect.
  • Has serious or permanent impairment of health, development of wellbeing though abuse or neglect.

An SCR is also required when:

  • There are concerns about the way in which local professionals and services work together to protect adults at risk of harm.
  • Serious abuse takes place in an institution or when multiple abusers are involved.
  • When incidences or a case involving at-risk adults is clearly in the public interest.

Purpose of SCRs

The overall purpose of an SCR is to learn and improve. There are four areas in particular which can contribute to further learning and improvement. They can be helpful to:

  • Understand why an adult came to harm.
  • Identify contributory factors to the harm of an adult.
  • Agree actions to prevent future deaths or serious harm occurring again.
  • Look at examples of good practice and agree how this can be used to improve safeguarding practice.

Questions assisting effective SCRs

There are numerous questions which can be asked which can help make a SCR more effective.

What happened? Overview of the case to establish the facts

What could have been done to prevent abuse and/or neglect? What actions could have 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?

Local body: Local Adult Safeguarding Partnership (LASP)

Local Adult Safeguarding Partnerships (LASP) are the lead local agencies and are responsible for adult protection in their local areas. They develop community-based prevention plans, which increase awareness of adult safeguarding in each of their local areas. These plants are based on guidance provided by the Northern Ireland Adult Safeguarding Partnership (NIASP).

Each Local Adult Safeguarding Partnership takes responsibility for carrying out its own review procedures to investigate serious and untoward incidents. These are reported to the NIASP to then decide if anSCR is required.

LASPs exist in Health and Social Care Trust areas and aim to support the six Health and Social Care Trusts across Northern Ireland: Belfast HSC Trust, South Eastern HSC Trust, Wester HSC Trust, Southern HSC Trust, Northern HSC Trust and the Northern Ireland Ambulance Service.

Each Health and Social Care Trust, with the support and input of the LASP, develops itsown Adult Safeguarding Operational Procedures.

Regional body: Northern Ireland Adult Safeguarding Partnership (NIASP)

 NIASP is a multi-agency, multi-disciplinary partnership. It brings together representatives from a range of statutory, community and voluntary organisations, which have a significant contribution to make to the safeguarding of vulnerable adults.

The NIASP has many different functions including:

  • Developing safeguarding strategy, guidance and operational policies; monitors trends, and evaluates the effectiveness of LASPs.
  • Seeking to support continuous improvement in preventative and early intervention services, as well as conduct Serious Case Reviews (SCR) when necessary and report findings to the Department for Health (DfH).
  • Working to build effective links between the NUASP and Multi-Agency Risk Assessment Conferences (MARAC); Public Protection Arrangements in Northern Ireland; the United Kingdom Human Trafficking Centre and the United Kingdom Border Agency.
  • Producing annual reports which provide updates on progress towards the Strategic Safeguarding Plan and annual Safeguarding Work Plans.

For further guidance on regional and local safeguarding partnerships, select the link: Regional and local safeguarding partnerships guidance.

Previous Safeguarding Adults Reviews and learning

Lessons learned from previous high-profile SCRs have contributed to the current safeguarding practice and policies that Northern Ireland is currently working towards.

The following SCRs were high profile, receiving national attention and can be considered key cornerstones to the improvements and development of adult safeguarding practice in England.

Select each name for more information.

Winterbourne View

Orchid View

Steven Hoskin

The following case is specific to Northern Ireland. It is an independent review into safeguarding ordered by the DfH. Independent reviews can be ordered where there are national lessons to be learned to improve safeguarding practice nationally. Select the title for more information.

Dunmurray Manor Care Home