Bath & North East Somerset Community Safety and Safeguarding Partnership (BCSSP) (BathNES)

As set out in the Care Act 2014:

(1)  A Safeguarding Adult Board (SAB) must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—

• there is reasonable cause for concern about how the SAB, members of it

or other persons with relevant functions worked together to safeguard the adult, and

• the adult has died, and it is known or suspected that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died), or
• the adult is still alive, and it is known or suspected that the adult has experienced serious abuse or neglect.

Indicators that the criteria have been met, may include:

• The adult may have died if no intervention had occurred.
• The adult has experienced lasting harm.
• The adult has diminished capacity or quality of life due to physical or psychological effects resulting from abuse or neglect.

A discretionary SAR is carried out when the absolute duties as set out above do not apply. Under Section 44 of the Care Act, a SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs), where it believes there is value in doing.

In 2024 an additional fourth recommendation was added within the Care Act 2014 relating to the death of rough sleeping.

In compliance with the Care Act 2014 (“Section 44”), SABs should proactively commission Safeguarding Adult Reviews in cases of deaths involving rough sleeping. There should also be a clear focus on implementing learnings from the reviews.

Therefore, deaths for those who have been experiencing rough sleeping will now be undertaken under the SAR process by the BCSSP provided that they meet the SAR criteria.

Once a referral has been accepted, the PRG will:

• Agree the terms of reference for the SAR, included the timeframe for inclusion
• Identify the relevant agencies that need to be involved
• Agree the responsible person for communicating with the adult and/or their family or advocate.
• Consider the appropriateness of communicating with the individual alleged to have caused the abuse or neglect.
• Agree a timescale for completion of the SAR, which in any event should be within six months of receipt of referral.
• Agree a methodology most likely to identify and facilitate learning
• Identify an author/facilitator for the SAR.

The BCSSP has agreed that for reviews meeting the mandatory duty, the author/facilitator must be external to any agency/organisation represented on the BCSSP

Where a referral does not meet the mandatory duty for a SAR, and a discretionary option is elected to be undertaken, an external person may be appointed or an individual working in B&NES if they:

• Have the skills required to undertake the review
• Work for an organisation or agency that is not involved in the review

The referrer should be notified of the decision made

If the BCSSP PRG do not believe the conditions for a SAR have been met, the rationale for this decision should be clearly recorded. If there is no reason to conduct a mandatory SAR, the reason that a discretionary SAR is not being carried out should be clear.

The referrer should be notified of the decision made.

If the referrer is not satisfied with the decision, they can raise this to the Business Unit for formal consideration.

If the SAR criteria is not met, the Practice Review Group could consider alternative learning processes such as a local multi-agency learning event, single agency review or learning event, a multi-agency audit or a thematic learning review/event.

Once a SAR has been agreed, the BCSSP Business Unit will inform the Chief Executive Officers of all agencies involved that the SAR is going ahead. They will also seek to establish the SAR panel. Panel members will be senior professionals from the agencies who provided services to the individual but had no line management responsibility for the practitioners directly involved. The role of the panel member is to:

• Prepare and submit a chronology of agency involvement for their organisation
• Consider all written information, refine the questions for the review and agree which practitioners should be invited to assist the review process.
• Feedback to their own organisation any immediate single agency issues that need to be addressed.  
• Work together with the panel to review the totality of the information gathered, contribute to the analysis, findings and recommendations and identify issues for the BCSSP
• Agree a final draft of the report.

It is expected that those undertaking a SAR will have appropriate skills and experience, which will include:

• Independence from the case under review and the organisations involved
• Strong leadership and the ability to motivate others
• Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics
• Collaborative problem-solving experience and knowledge of participative approaches
• Good analytical skills and ability to manage qualitative data
• Safeguarding knowledge
• Inclined to promote an open, reflective learning culture

During the review, the author will be responsible for:

• Achieving consensus of opinion about the key areas of learning and/or areas of change identified
• Ensuring the agency representatives work together positively
• Ensuring an appropriate level of challenge is provided throughout the process
• Considering good practice as well as areas for development and including them in the report
• Agreeing with agencies and the Chair of the PRG who will be the named individual responsible for contact with the individual or family members and how the individual or their family/friends will contribute to the review
• Keeping the PRG Chair updated on progress

The person authoring the review is also responsible for:

• Ensuring the report is written in plain English
• Clearly identifying the learning points and recommendations being made
• Ensuring the report is suitable for publication without needing to be amended or redacted
• Seeking agreement from all contributing agencies that they are satisfied that the report reflects the information shared and discussions held as part of the review
• If agreement cannot be obtained, the Executive Board will be notified that agreement has not been obtained from all agencies, and they will have the final decision.
• Agreeing with the PRG Chair and the Executive Board of the BCSSP how the report will be shared with the BCSSP as well as the individual/family
• Participating in any agreed communication arrangements regarding the report, including public information

The appointed reviewer will have access to the BCSSP administrative and business management support.

The selected methodology will affect the level of multi-agency meetings required to complete the review. Each agency will provide information as required.

The reviewer leading the SAR will agree with all agencies involved how reports will be presented during the review process. This may require reports that are anonymised through redaction and an agreement made on the abbreviations to be used by all agencies. It may be that consent is obtained from the individual/family that their information can be shared in an un-redacted form during the review process.

The report produced at conclusion of the SAR will be anonymised with regard to individuals – including the individual, their families and professionals. Agency names and job roles can, however, be included.

The final draft report will include draft recommendations, which should be reflected in the action plan provided with the report.

In order to carry out its functions, the BCSSP will need access to information that a wide number of people or organisations may hold.

Section 44 of the Care Act 2014 requires organisations and partners on the BCSSP to co-operate in and contribute to the carrying out of a SAR with a view to identifying lessons to be learnt from the adult’s case and applying those lessons to future cases

Section 45 of the Care Act 2014 places a legal duty on any organisation or individual asked to provide relevant information to share what they know with the BCSSP, or the person identified (i.e. the person leading the review) This section applies if the information being requested on behalf of the BCSSP is to enable or assist it to perform its functions. Undertaking a SAR is a required function of the BCSSP, therefore S.45 applies to all requests for relevant information made as part of a SAR process.

If a partner agency refuses to provide relevant information this can be escalated to the BCSSP Adult Safeguarding Strategic Assurance Group (SAG) in line with the BCSSP escalation policy. If resolution cannot be reached the Adult Safeguarding SAG can engage Care Quality Commission (CQC), NHS England/ICB commissioners, Local authority contract monitoring teams and professional regulators where appropriate to seek to resolve the engagement.

Care and Support statutory guidance 2025 states that the process for undertaking SARs should be determined locally according to the specific circumstances of individual circumstances. No one model will be applicable for all cases. The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for family and friends of adults who have died or been seriously abused or neglected. (para 14.170)

The most appropriate methodology for conducting the SAR should therefore be determined on a case-by-case basis, as agreed by the BCSSP PRG.

The approach should be proportionate to the scale of the abuse or neglect that has occurred, the impact on the person and the level of complexity in the issues to be examined during the review.

The adult and/or their family or representative should be consulted when deciding how to complete the SAR, so that they can be as involved as possible.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of people who have died or been seriously abused or neglected.

A summary of approaches and recognised methodologies that can be used are cited in Appendix 4. It is recognised that this list is not exhaustive, and the PRG may wish to use its collective expertise to recommend an appropriate methodology.

The individual and/or their family will be informed if a review is going to take place. They will be offered the opportunity of contributing to the review process. How that is done will depend on the methodology used and the views of the family

If the adult is alive, there is a statutory duty to ensure they receive the support they need to enable them to understand and/or participate in the SAR process.

If they are already in receipt of advocacy support under Section 67 of The Care Act, The Mental Capacity Act 2005, or the Mental Health Act it is appropriate to establish whether the existing advocate is able to provide this support.

Otherwise, the duty to appoint an advocate under Section 68 of the Care Act 2014 must be considered.

Staff directly involved in working with an individual subject to a SAR will be notified by their employing agency that the decision has been made to undertake the review

Information about the review process and how the staff members may be involved in the review will be fully explained by their employing organisation

Support to staff members will be provided by the employing agency/organisation in line with their HR requirements.

Agencies may need to consider what support is required if a systems approach is used to undertake the review, as this approach requires a high level of reflection and interaction from individuals. Whilst the outcomes of this approach should be positive, individuals can experience it as being challenging.