Adult support and protection: learning review guidance

1. Introduction

The purpose of this guidance is to support a consistent approach to conducting Adult Protection Learning Reviews and improve the dissemination and application of learning both locally and nationally. Supporting and protecting adults at risk of harm is an inter-agency and inter-disciplinary responsibility supported strategically by the Adult Protection Committee.

This guidance is primarily intended for members of Adult Protection Committees (APCs), but is also of clear relevance to Chief Officer Groups, the Care Inspectorate, and a wide range of agencies and their staff.

This guidance replaces the Interim National Framework for Adult Protection Committees for Conducting a Significant Case Review (2019). It has been drafted to reflect and align to the fullest possible extent with the Guidance for Child Protection Committees Undertaking Learning Reviews (2021). As such it reflects a strong emphasis on learning from practice. Accordingly, the previous process involving Initial and Significant Case Reviews has been replaced with an overarching Learning Review process.

An Adult Support and Protection Learning Review is a means for public bodies and office holders with responsibilities relating to the protection of adults at risk of harm to learn lessons from considering the circumstances where an adult at risk has died or been significantly harmed. It is carried out by the Adult Protection Committee under its functions of keeping procedures and practices under review, giving information and advice to public bodies and helping or encouraging the improvement of skills and knowledge of employees of public bodies as set out in section 42(1) of the Adult Support and Protection (Scotland) Act 2007.

Learning Reviews should be seen in the context of a culture of continuous improvement and will focus on learning and reflection around day-to-day practices, and the systems within which practice operates.

A Learning Review should seek to:

• understand the full circumstances of the death of, or serious harm to, an adult
• examine and assess the role of all relevant services, relating both to the adult and also, as appropriate, to relatives, carers or others who may be connected to the incident or events which led to the need for the review
• explore any key practice issues and why they might have arisen, including identifying systemic issues. Consider the question of "How did the situation present itself to the practitioner at the time, and how did this lead to decisions and actions taken at the time?"
• establish whether there are areas for improvement and lessons to be shared, about the way in which agencies work individually and collectively to protect adults at risk
• identify areas for development, how they are to be acted on and what is expected to change as a result
• consider whether there are issues with the system and whether services should be reviewed or developed to address these
• establish findings which will allow the Adult Protection Committee to consider what recommendations need to be made to improve the quality of services.

This guidance supports the achievement of the Adult Protection Committee's objectives by helping those responsible for reviews to:

• undertake them at a level which is necessary, reasonable and proportionate
• adopt a consistent, transparent and structured approach
• identify the skills, experience and knowledge that are needed for the review process
• address the needs of the many different people and agencies who may have a legitimate interest in the process and outcome