Background Information

The Purpose of Safeguarding Adult Reviews

Care and support statutory guidance provides a useful summary of the purpose of Safeguarding Adult Reviews (SARs):

“SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again.

Its purpose is not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.

It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them.”

Definition of a Safeguarding Adult Review

The definition of Safeguarding Adult Reviews as set out in the Care Act 2014 legislation is:

Statutory – Section 44

The 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:

1. There is reasonable cause for concern about the SAB, members of it or other persons with relevant functions worked together to safeguard the adult; and
2. Either
   1. The adult has died and the SAB knows or suspects 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
   2. The adult is still alive and the SAB knows or suspects that the adult has experienced serious abuse or neglect

Discretionary – Section 44 (4)

A SAB may also 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). SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

Purpose of this Guidance

This guidance is intended to provide specific guidance to agencies when asked to complete a Key Event or Organisational Chronology for a Safeguarding Adult Review. The aim is to ensure a professional standard and consistency across agencies.

Who should complete the Chronology?

Chronologies should be completed by a senior member of staff who has had no involvement with the case. This individual should have access to all relevant information and records relating to the case and should be given the opportunity to query facts with staff where necessary.

A Senior Officer within the agency should quality assure and sign off the chronology prior to its submission.

Purpose of the Chronologies

What is a Chronology?

A chronology is a succinct summary and overview of the significant dates and events in an adult with care and support needs’ life. Chronologies are also used to capture significant organisational changes.

When undertaking a Safeguarding Adult Review all relevant agencies will usually be asked to complete a ‘Key Events Chronology’ of their agency’s involvement and a chronology of any organisational changes which may have impacted on frontline practice during the same period.

Individual agency chronologies will be collated to produce an Integrated Chronology. (This will often be colour coded to facilitate an ‘at a glance’ overview of agency involvement.)

Why are Chronologies Useful?

Adults with care and support needs are most effectively safeguarded if professionals work together and share information. Single factors in themselves are often perceived to be relatively harmless. However, if these factors multiply and compound one another, the consequences can be serious, and on occasions, devastating.

Chronologies are used as an analytical tool to help understand the impact of events and changes on a adult with care and support needs progress. They can reveal risks, concerns, patterns and themes, strengths and weaknesses within a family, and can identify periods of professional involvement, support and its effectiveness. Chronologies enable the Review Team to gain a more accurate picture of the whole case and highlight gaps and missing details that require further assessment and identification.

It is recognised that the relevance and / or significance of an event can change over time. A historical event which appeared insignificant or irrelevant at the time may become highly significant in the light of further information or subsequent events.

How to Complete a Chronology

What is a Key Event Chronology?

A ‘key event’ is a significant incident that impacts on the adult with care and support needs safety and welfare, circumstances or home environment. This will require a professional decision and / or judgement based upon the adult with care and support needs’ individual circumstances.

It is crucial that the information recorded in a chronology is relevant and succinct to avoid key events becoming lost in a mass of insignificant and irrelevant detail.

The events or incidents that should be recorded will vary from case to case depending upon the nature of the risks and harm. The following are some examples, but it should be noted that this is not an exhaustive list:

• Contacts or referrals about the adult;
• Assessments undertaken; including Capacity and Best Interests
• Strategy Discussions
• Meetings and Conferences;
• Section 42 Enquiries;
• Non-accidental injury and significant injury or neglect events;
• Attendance / admittance to hospital;
• Births, deaths, serious illness of adults and others within the family;
• House moves;
• Changes in family composition, including new partners, separations, non-family members moving into family home;
• Criminal proceedings and outcomes;
• Civil proceedings involving the family;
• Change in GP;
• Self-referrals and any referrals to other agencies / teams;
• Court proceedings and changes in legal status;
• Police logs detailing relevant incidents at family home or in relation to family members, such as reported incidents of domestic abuse, drunken / anti-social behaviour;
• Attempted suicide or overdose;
• Specific support offered to the adult;
• Events showing capacity of the adult to work in partnership and engage with professionals;
• Frequent presence of unknown adults;
• Any event in the adult’s life deemed to have a significant effect on them, such as separation from main carer leading to poor attachment.

What Time Period should the Chronology Cover?

The time period covered by each review will be identified based on the potential learning likely to be achieved. There is little value in identifying weaknesses in professional practice or procedures that have already changed. All agencies will be informed of the relevant timeline when asked to complete the chronology template: this will usually be included in the ‘Case Summary’ provided or the Terms of Reference. Please focus on this time period when completing your chronology. However, do include any Key Events outside of this time period if they are likely to be required to understand the pattern of abuse or neglect and whether early help interventions could have been beneficial.

Why Do I Also Need to Complete a Chronology of Organisational Changes?

The purpose of a Safeguarding Adult Review is to identify improvements to current safeguarding arrangements to prevent, or reduce the chance of, similar incidents in the future. Improvements may be linked to practice issues but they frequently also require changes to the organisational and “systems” factors that shaped behaviour (such as organisational/team aims or culture and the level of resources available to deliver services.)

The chronology of significant organisational changes is, therefore, important to help to identify where organisational and “systems” factors influenced actions.

Again, it is crucial that the information on organisational changes recorded in a chronology is relevant and succinct to avoid key events becoming lost in a mass of insignificant and irrelevant detail.

NOTE: Disclosure of Chronologies

Agencies should be aware that a request may be made by the Police or Court (including the Coroners Court) for chronologies to be disclosed when information is being gathered for a case. If requested, we will not provide a copy of your documents but will, instead, forward your contact details to the Officer seeking disclosure so that direct contact can be made.

_{Document produced with the kind permission of Worcestershire Safeguarding Children Partnership}