Serious case reviews (SCRs) are one means of learning the lessons arising from adverse, salient incidents and tragedies. Adult Safeguarding Boards in England are expected to have an SCR policy and procedure, to commission SCRs, to abstract and act on the learning, and to monitor the resulting action plans.
Since SCRs reflect a wide range of processes, the authors undertook a general review, drawing on their experiences of conducting and contributing to SCRs. They chose to pose sets of question‐prompts regarding the commissioning process, the management of the process, the appointment of a chair and author, the terms of reference, information‐sharing, confidentiality, involving relatives and making findings public. The compliance of the process with human rights legislation is also considered.
Whilst the authors acknowledge the responsibility of organisations to promote continuous and cumulative professional learning, they do not promote SCRs as the sole means of learning about the ways in which professionals and agencies work together to safeguard adults at risk of abuse.
The paper challenges the perception that SCR can be streamlined, structured, codified, and constrained.
