• Summary: The article reports findings from an audit of Serious Case Reviews into the death or harm of a vulnerable adult in England. Serious Case Reviews may be undertaken by local authorities in partnership with other agencies. There is little government guidance and practice appears variable.
• Findings: Interviews were undertaken in 2007 with persons who had been appointed to Chair Serious Case Reviews and with those who commissioned such Reviews or managed the process. The findings confirm the aspiration of such Reviews to be opportunities for learning from mistakes, if any, and to thereby offer greater safeguards for vulnerable adults. In practice however, the conduct of such Reviews may be difficult if there is a lack of cooperation, a lack of resources and if there is little opportunity to share findings and recommendations outside the locality.
• Application: This study supports the sharing of Serious Case Reviews to encourage learning from mistakes and missed opportunities to safeguard vulnerable adults. It also found agreement among those with experience in such Reviews that greater guidance on conduct and collaboration would be welcome.
Association of Directors of Adult Social Services (ADASS). (2006). Vulnerable adult Serious Case Review guidance: Developing a local protocol. London: Association of Directors of Adult Social Services. Retrieved 28 August 2008 from: http://www.adss.org.uk/publications/guidance/vulnerableadult.pdf.
Association of Directors of Social Services. (2005). Safeguarding adults. A national framework of standards for good practice and outcomes in adult protection work. London: Association of Directors of Social Services.
4.
Association of Directors of Social Services (2010). Safeguarding adults: A national framework of standards for good practice and outcomes in adult protection work. London: Association of Directors of Social Services.
5.
AxfordN.BullockR. (2005). Child death and significant case reviews: International approaches. Edinburgh: Scottish Executive.
6.
BenbowS. M. (2008). Failures in the system: Our inability to learn from inquiries. Journal of Adult Protection, 10(3), 5–13.
7.
BostockL.BairstowS.FishS.MacleodF. (2005). Managing risks and minimising mistakes in services to children and families. London: Social Care Institute for Excellence.
8.
BrandonM.DodsworthJ.RumballD. (2005). Serious case reviews: Learning to use expertise. Child Abuse Review, 14(3), 160–176.
9.
BrownH. (2009). The process and function of serious case review. Journal of Adult Protection, 11(1), 38–50.
10.
BrymanA. (2001). Social research methods. Oxford: Oxford University Press.
11.
ButlerT. (2004). Learning from Rowan Ward: Developing an audit tool to improve the systems and processes for quality of care and safety of service users. Journal of Adult Protection, 6(4), 22–26.
DentR. J.JowittS. (2003). Homicide and serious sexual offences committed by children and young people: Findings from the literature and a serious case review. Journal of Sexual Aggression: An International, Interdisciplinary Forum for Research, Theory and Practice, 9(2), 85–96.
14.
Department of Children, Schools and Families. (2010). Statement: Ed Balls – Serious Case Review Executive Summaries should be more transparent and thorough. Issued 17 March, retrieved 15 May 2010 from: http://www.dcsf.gov.uk/pns/DisplayPN.cgi?pn_id=2010_0068.
15.
Department of Health (DH) (2008). Safeguarding adults. A consultation on the review of the ‘No secrets’ guidance. London: Department of Health.
16.
Department of Health (DH) (2009). Report on the consultation: The review of No secrets guidance. London: Department of Health.
17.
Department of Health (DH) (2010). Clinical governance and adult safeguarding: An integrated process. London: Department of Health.
18.
Department of Health and Home Office (2000). No secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London: Department of Health.
19.
Department of Health and Home Office and Department for Education and Employment (1999). Working together to safeguard children. London: The Stationery Office.
20.
GraneheimU. H.LundmanB. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112.
21.
Healthcare Commission. (2007). Investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust. London: Healthcare Commission.
22.
HitchenS. (2007). The use of collaboration to produce more effective serious incident inquiry reports. Journal of Integrated Care, 15(6), 22–29.
23.
HM Government. (2006). Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. London: HM Government.
24.
Independent Inquiry Team. (2004). The Avonside review: Report of the Independent Inquiry Team. Birmingham: Birmingham & Solihull Mental Health NHS Trust.
25.
IrvineA.DrewP.SainsburyR. (2010). Mode effects in qualitative interviews: A comparison of semi-structured face-to-face and telephone interviews using conversation analysis. University of York. Research Works, 03
26.
ManthorpeJ.MartineauS. (2009). Serious Case Reviews in adult safeguarding. London: Social Care Workforce Research Unit, King's College London.
27.
ManthorpeJ.MartineauS. (2010). Serious Case Reviews in adult safeguarding in England: An analysis of a sample of reports. British Journal of Social Work, doi: 10.1093/bjsw/bcq100, first published online: 1 September 2010.
28.
ManthorpeJ.StevensM.RapaportJ.ChallisD.JacobsJ.NettenA.JonesK.KnappM.WilberforceM.GlendinningC. (2010). Individual budgets and adult safeguarding: Parallels or converging tracks? Further findings from the evaluation of the Individual Budget pilots. Journal of Social Work, doi: 1468017310379452, first published online: 21 September 2010.
29.
Mencap (2009). Mencap response to Safeguarding adults: A consultation on the Review of the ‘No Secrets’ guidance. London: Mencap.
30.
Multiple Sclerosis (MS) Society. (2009). Safeguarding adults: A consultation on the review of the ‘No Secrets’ guidance, Submission from the MS Society, London.
Penhale, B., Perkins, N., Pinkney, L., Reid, D., Hussein, S., & Manthorpe, J. (2007). Partnership and regulation in adult protection: The effectiveness of multi-agency working and the regulatory framework in adult protection. Final report to the Department of Health, University of Sheffield and Social Care Workforce Research Unit, King's College London.
33.
ReithM. (1998). Community care tragedies: A practice guide to mental health inquiries. Birmingham: British Association of Social Workers.
34.
Sense. (2009). Sense's response to Safeguarding Adults – a consultation on the review of the ‘No Secrets’ guidance, Sense, London.
35.
StanleyN.ManthorpeJ. (2001). Reading mental health inquiries: Messages for social work. Journal of Social Work, 1(1), 77–99.
36.
StanleyN.ManthorpeJ. (2004). The age of the inquiry: Learning and blaming in health and social care. London: Routledge.
