Learning not blame: reflections on staying on the right side of the line for a Safeguarding Adults Review

Purpose The author will describe the operational tasks of S.44’s statutory mandate: for example, commissioning the review; being responsive to the representatives of the relevant agencies concerned; securing pharmacological/medical advice; adding Ben’s death to the review; engaging with relatives; and ensuring that “lessons” were foregrounded. How the review was set up/recognising the standout features from the beginning/managing the situation when an agency is withholding information/“drip feeds” information into the review; navigating/steering the Safeguarding Adults Review (SAR) alongside other processes – police/inquest/Care Quality Commission. Design/methodology/approach This practice paper describes the experiences of coordinating a complex SAR into the deaths of three adults at Cawston Park Hospital in Norfolk. Findings The system insights that SARs give us prompt exploration of how to inject this learning into current discourse on how we better protect the most vulnerable in our communities. Originality/value The purpose of this paper is to explore the process and requirements of conducting a complex SAR from the perspective of a safeguarding adults board manager. It will be of interest to anyone who is involved in SARs, in particular safeguarding adult board chairs, board managers, members of SABs and SAR authors as management of SAR is one of the three statutory duties of a SAB.