Serious Case Review Guidance

1 January 2018

There are occasions when failure to protect individuals from abuse are identified. These occasions are then reviewed, primarily through Serious Case Reviews. Serious Case Reviews are not inquiries into why a person dies, for example, or who is culpable, but to facilitate learning and provide for the support of the staff involved. Therefore, reviews provide a means by which staff can learn retrospectively from mistakes or serious incidents; or even ‘near misses’ (Bostock et al., 2005; Fish et al., 2008) to promote a better, safer environment for vulnerable people.

Two such cases that showed failure of the care providers to protect vulnerable adults are: ‘Winterbourne View Hospital’ 1 for people with learning difficulties where an investigation resulted in the convictions of 11 staff members for assault and ‘Parkside House’2 residential home, Northampton, where five people of advanced years died while living in residential care, where the Care Quality Commission later instigated proceedings to cancel the home’s registration. The studies identified the sources of the negligent practices performed by the various care providers for the people in their care.

In the cases above highlighted it is evident that failure to communicate repeated possible safeguarding issues was a possible factor in the severity of the tragedies. Lack of experienced support or care staff, therefore, can lead to inadequate communication and provision of care. That is, evidence of abuse, whether by omission or commission was not identified and reported. Neglect or even evidence of repeated physical, psychological or emotional abuse, for example, was not communicated to the necessary authorities and therefore led to the tragic results that necessitated the investigations.

Experienced staff clear as to what their job role entails coupled with good inter-agency communication may have prevented the tragic events in these examples. It is, therefore, necessary to ensure that all staff possesses the necessary skill set through adequate training and supervision to enable them to identify, correct or report malpractice through the correct channels, as the need arises. Keeping care staff up to date regarding their charges needs and welfare is a necessity to implement changes and monitor working practices. Had this system been in place then perhaps the failures in their duty of care may have been prevented.

Ultimately, poor management practices and procedures led to the tragedies, apparently with poor oversight across all levels. The failing on the many levels by care staff to challenge the quality of care provided highlights the need for adequate training, supervision, peer support and other agencies communication.

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