Surrey Safeguarding Adults Board report on Mr ‘D’ was the first time I had dipped my toe into the murky waters of Serious Case Reviews and it turned out to be a fascinating experience. Initially, there’s a period of waiting for other people to do their bit, then the information starts coming in and you have a dawning realisation that this is going to be just as complicated as you feared it might be when you agreed to the undertaking all those weeks ago. Although all Individual Management Review authors from each partner agency are expected to use the same template and work to the same terms of reference, the reports vary in depth, style and quality, so making sense of them can be daunting. In this case, the safeguarding team produced a master chronology from all the individual ones, which ran to over 90 pages, and it was fascinating to see the same incidents recorded by different agencies, e.g. a visit to A and E could be recorded by the ambulance service, various professionals in the patient record, social services emergency duty team and the police.
It was as I was putting together the ‘Key Events’ section of the report that I realised that I was the only person who had the whole story. Writing the report therefore became even more of a responsibility to make sure that I got the detail right, as well as drawing out the important themes from the analysis, coming to conclusions that were fair and based on the evidence before me and shaping recommendations that would be useful to the various agencies and to the safeguarding board itself.
Importantly I needed the confidence to seek further information or clarification to answer questions that arose as I was doing the work or to fill a gap in the story. There was broad agreement at the Safeguarding Panel about my conclusions and the discussions and negotiations about the final recommendations were considered, honest and constructive. All in all I was pleased with the final product and am hopeful that all agencies really will use it to improve practice and the ways in which they endeavour to work together on behalf of vulnerable people.