Learning from Practice

The Boards have a duty under Working Together and the Care Act to “learn from practice” where something has happened which they feel show the partners of the Board have not worked together to effectively safeguard people which they need to learn from and improve practice so that similar issues do not occur in the future.

Alternatively the Boards may feel they need to learn from incidents where the partners have worked particularly well together to ensure continuous improvement.

There are legal instructions as to when and how a Serious Case Review (SCR) or cases relating to children and young people and a Safeguarding Adults Review (SAR) for adults at risk should be carried out.

Where it is decided by that the criteria are not met, the subgroups in charge of screening the cases will usually prescribe another course of action to ensure any learning is not lost. These might be a single agency review, critical incident review or other multi-agency review.

The Boards have a duty to ensure that there is continual learning and improving in safeguarding through single agency and multi-agency case audits, case reviews and (when necessary) SAR and SCR.

Local Learning Reviews

If a case does not reach the threshold for a SAR or SCR an analysis of the case may reveal important lessons that could improve safeguarding practice.

In some cases the Board will commission a multi-agency Learning Review if a case does not reach the threshold for SAR or  SCR but the  relevant subgroup believe that better understanding of the case may reveal important lessons that could improve safeguarding practice.

This helps ensure that the approach taken to reviews is proportionate according to the scale and level of complexity of the issues being examined.

Whenever possible we will seek to include front line staff and managers, as well as parents, carers and young people in these reviews. Actions resulting from the findings of these reviews receive the same rigorous monitoring and follow up as SAR and SCR, so that findings from all reviews make a real impact on improving outcomes.


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