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Serious Case Reviews

A Serious Case Review should be considered when:

  • A vulnerable adult dies and abuse or neglect is known or suspected to be a factor in their death 
  • A vulnerable adult has sustained a potentially life threatening injury through abuse or neglect and the case gives rise to concerns about the way in which staff and agencies work together to protect vulnerable people
  • Serious abuse takes place in an institution or when multiple abusers are involved
  • There is actual abuse or mistreatment of sufficient complexity or significant public interest that a single agency review would not be considered adequate or appropriate
  • There is a "near miss" in which although the actual harm was minimal, the potential for harm was very high
  • Other requests made by the Coroner, MPs, Elected Members and other interested parties. A Safeguarding Adult referral need not have been made in order to warrant a Serious Case Review.     

Serious Case Reviews are not designed to re-investigate a case, nor are they to apportion blame. They are to establish whether there are any lessons to be learnt about the way in which staff and agencies work together to safeguard vulnerable people. The review should also establish whether the Safeguarding Adults procedures are effective or whether they need to be amended. 

Serious Case Reviews, where appropriate, are undertaken by a review group agreed by the Cumbria Safeguarding Adults Board. The role of the Board is to receive and consider requests for Serious Case Reviews whilst ensuring appropriately managed and competent resources are made available. 

The review group will collate and assess the evidence and specialist advice may be sought. Key points and proposals for action will be recommended and an Executive Summary will be formed. The outcome of the report from the review group is presented to the Board and recommendations for future actions are made. 

All Serious Case Reviews carried out within the year are referred to within the Board Annual Report.

Findings and recommendations from the two Serious Care Reviews undertaken in Cumbria recently by the Cumbria Safeguarding Adults Board can be downloaded here:

Serious Case Review - Executive Summary - Mrs W and Mr H (PDF, 87KB)
Serious Case Review - Executive Summary - Mrs X and Mr X (PDF, 98KB) 
Safeguarding Adults Review - Adult Y (PDF, 122Kb)