Professional

Learning and improvement

Case reviews

Wigan Safeguarding Adults Board (WSAB) is committed to undertaking case reviews to establish whether there are lessons to be learnt from the circumstances of a specific case. Our approach is made of both:

  • Discretionary case reviews or Brief Learning Reviews (BLRs)
  • Statutory reviews or Safeguarding Adult Reviews (SARs) (as defined within the Care Act 2014).

Both review processes use similar methodologies based on reflective learning principles and whole system approach. It involves a multi-agency review to determine what individuals and agencies could have done differently that may have prevented neglect, abuse, harm or a death from taking place. A Brief Learning Review will often look at earlier opportunities and the focus is on "near misses".

Why do we conduct case review?

The purpose of a case review is not to apportion blame, it is to promote effective learning and improvement to prevent similar issues occurring again. Find out about our overarching policy and process for undertaking case reviews by viewing our procedure document:

A case review highlights key recommendations for system, practice, policy or process changes and actions are managed within the WSAB delivery group framework. These are analysed from both a local, regional and national perspective to establish key areas for local improvement, training or service delivery; these in turn inform the WSAB overarching strategy.

Safeguarding Adult Reviews

From 2019, a key element of the learning process has been to publish our SAR case reviews via briefing documents (pre 2019 we published full reports) so that practitioners or other interested parties can access the learning themselves. In the case of SARs that the WSAB has decided not to publish, for transparency these are noted but with no additional briefing.

Review One - Tom

Male in his 30’s with a learning disability who suffered a sexual assault by a minor. A decision has been taken not to publish this report, as the carers for the victim are all alive and being actively worked with, and despite attempts at anonymity, details within the report would be too recognisable.

Review Two - Peter

Adult male leading chaotic / complex lifestyle assaulted by associates (some evidence of financial abuse) and later died of injuries (offenders were later sentenced to prison). Review focused on the services response to complex clients from an early intervention perspective.

Review Three - Brett

Brett beganto struggle with his mental health in his early 20’s and was given a diagnosis of schizophrenia. Following two periods of inpatient care under mental health, sadly Brett took his own life in Spring 2018.

The main themes within the case are: Mental Health, Suicide.

Review Four - Colin

Colin is an elderly man who was admitted to hospital in a poor state of health due to his care and support needs not being met by his informal carer following a failure of services to respond to concerns or to assess Colin's needs.

The main themes within the case are: Self Neglect / Neglect and Acts of Omission, Informal Carer, Pressure Ulcers.

Review Five - Diane

Diane died as result of fire in her home. She was considered complex and was presenting to services with increasing medical needs, both physical and mental. Diane had a history of trauma and self-neglect, as well as ongoing concerns regarding self-neglect and hoarding, especially in relation to refusing care and support.

The main themes within the case are: Fire Risk, Self-Neglect, Learning disability, Trauma.

Review Six - Helen

Helen was an elderly lady residing in a care home. Helen was found to have died following being trapped in the telescopic bed rails that were fitted to her bed. The bed rails had not been fitted correctly. A police investigation was completed; however, the CPS made the decision that no criminal prosecutions were being pursued.

The main themes within the case are: Neglect and Acts of Omission and Organisational Abuse.

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