Adult support and protection: learning review guidance

2. Key Features of Learning Reviews

The key Features of a Learning review are:

I. Inclusiveness, collective learning and staff engagement

A learning Review should be multi-agency, bringing practitioners, managers and others relevant to the case together with the review team in a structures process in order to reflect, increase understanding and identify key learning.

II. Support for staff

Support for staff is critical and should be integral to the review process in order that they can participate fully in the process, reflect on their practise, share their knowledge and contribute to the emerging learning.

III. A systems approach

The learning review does not stop at the points when shortcomings in professional practise have been recognised. It moves on to explore the interaction of the individual with the wider context, including cultural and organisational barriers, in order to understand why things developed in the way they did. The focus is on:

• What happened?
• How some assessments were made?
• Understanding how people saw things at the time
• What knowledge was drawn on to make sense of the situation, the resources available and the emotional impact of the work
• Effective practice
• Identification of learning points and how these will be actioned and implemented in future practise and systems

IV. Proportionality and flexibility

The situations under review will inevitably be complex and diverse and this therefore requires a streamlines, proportionate and flexible approach to ensure effective learning. This flexible approach remains grounded in the underpinning principles and values of Learning reviews.

V. Timing and Timelines

Long review processes should be avoided. Optimum learning arises not just when the process allows significant events to be identified but also when it is relevant for the current practise context.

Underpinning Principles and Values

Learning Reviews are underpinned by the following core principles and values:

• They promote a culture that supports learning
• Their emphasis is on learning and organisational accountability and not on culpability
• They recognize that a positive shared learning culture is an essential requirement for achieving effective multi-agency practice
• They are objective and transparent
• They ensure that staff are engaged and involved in the process and supported throughout the period of the review
• They recognize the complexities and difficulties in the work to protect adults at risk of harm, and their families and carers
• They produce learning which can be disseminated, both at local and national level, so it directly impacts on and positively influences professional practice and organisational systems

Creating the preconditions for learning

Learning Reviews are not investigations. They are an opportunity for in-depth analysis and critical reflection in order to gain greater understanding of inevitably complex situations and to develop strategies to support practice and improve systems across agencies.

Reviewing complex situations can raise anxiety in individuals and organisations. This anxiety can block learning by generating defensiveness, with a consequent inability to review and reflect. In order to create the preconditions for learning it is essential that individuals who are part of the review process feel safe so that they can begin to honestly consider what has happened and engage in appropriate and constructive questioning and challenge. This will then result in the development of ideas and realistic and realisable action plans.

Effective leadership is crucial to creating the preconditions for learning. Chief Officers, who are accountable for all of the work of the APC, must promote and support local and national learning and improvement activity in the protection of adults at risk of harm as a matter of course, providing leadership and guidance in relation to the need to carry out Learning Reviews.

Criteria for undertaking a Learning review

An Adult Protection Committee will undertake a Learning review in the following circumstances:

1. Where the adult is, or was, subject to adult support and protection processes andthe incident or accumulation of incidents gives rise for reasonable cause for concern about how professionals and services worked together to protect the adult from harm, and one or more of the following apply:

(i) The adult at risk of harm dies and

• harm or neglect is known or suspected to be a factor in the adult's death;
• the death is by suicide or accidental death;
• the death is by alleged murder, culpable homicide, reckless conduct, or act of violence.

or

(ii) The adult at risk of harm has not died but is believed to have experienced serious abuse or neglect

2. Where the adult who died or sustained serious harm was not subject to adult supportandprotection processes

(i) When the findings of an inquiry or review by another organisation orcourt proceedings, or a referral from another organisation gives rise to reasonable cause for concern about lack of involvement in relation to the Adult Support and Protection (Scotland) Act 2007

or

(ii) The Adult Protection Committee determines there may be learning to be gained through conducting a Learning Review.

Definition of an adult at risk of harm

The Act refers to an 'adult' as a person aged 16 or over, and Adults at Risk of Harm are defined as those adults who:

• are unable to safeguard their own well-being, property, rights or other interests
• are at risk of harm
• because they are affected by disability, mental disorder, illness or physical or mental infirmity are more vulnerable to being harmed than adults who are not so affected

Who Can Request a Learning Review?

Any agency with an interest in an adult's wellbeing and safety can request that a case be considered for review by the Adult Protection Committee where they consider the criteria for review is met. It should be noted that concerns raised by families and addressed through the relevant agency's normal complaints procedure may also be a trigger for a Learning Review, where the agency considers the criteria for a review is met. The agency addressing the complaint should refer the circumstances to the Adult Protection Committee for their consideration at the earliest opportunity.

Inter-related Investigations, reviews and other processes

As elaborated in Annex 7, there are a number of other processes, including criminal investigations and NHS Significant Adverse Event Reviews, that could be running in parallel with a Learning Review and this raises a number of issues including:

• relationship of the Learning Review with other processes, such as criminal proceedings and Health Board reporting and reviewing frameworks
• securing co-operation from all agencies, including relevant voluntary sector interests in relation to the release and sharing of information
• minimising duplication through the integration and coordination of these processes wherever possible
• ensuring a sufficient degree of rigour, transparency and objectivity

Depending on the case, there could be a number of processes which come into play which are driven by considerations wider than service failure or learning lessons across agencies. These can include disciplinary processes, criminal investigation, report of death to Procurator Fiscal or a Fatal Accident Inquiry. In addition to this, agencies should ensure that the areas for improvement identified and shared learning are directed through the relevant clinical and care, or quality assurance, governance arrangements.

These processes may impact on whether a review can be easily progressed or concluded; criminal investigations always have primacy. To help establish what status a Learning Review should have relative to other formal investigations, on-going dialogue with Police Scotland, COPFS or others to determine how far and fast the Learning Review process can proceed in certain cases must take place. Issues to be considered include:

• how to link processes
• how to avoid witness contamination
• how to avoid duplicate information being collected
• whether to postpone a Learning Review until determination of a parallel proceeding

There could be cross-cutting issues, for example, gender-based violence, human trafficking, or problematic alcohol and drugs use.

Processes can, and do, run in tandem, and the basic principles to follow are: check if there are other processes going on from the start; ensure good communication with each other; and ensure the relevant information is shared with the right parties. Above and beyond this, the priority is that the adult is, and remains safe, regardless of other ongoing investigations (including criminal investigations). Consideration should be given to the safety of other adults who could also be at risk of harm. The rights of staff or others who are under investigation, but have not been charged or found guilty, is another factor to be taken into account.