Decision-making about whether a case requires a mandatory SAR

Each SAB will have developed its own process to support consistent and sound decision-making about when a referral meets the criteria for a mandatory SAR and whether there should be consideration for a discretionary SAR (Section 44 of the Care Act 2014). Tool A and Tool B are two downloadable files that can be used to support the decision-making process.

Tool C – discussion prompts to consider common challenges that SABs experience in their SAR decision-making

Feedback from SABs indicates that the kinds of case that can often cause debate or disagreement about whether a mandatory SAR is required are those where:

· There is a lack of clarity or consensus about whether the adult had/s care and support needs.

Points for discussion

Care and support needs relate to help needed by an adult experiencing impacts from, for example, a learning or physical disability, mental illness or substance misuse. The help needed to manage and remain independent can include activities of daily living, maintaining social interaction, enabling the individual to play a fuller part in society, protecting them in vulnerable situations arising from issues. It is not necessary for the adult to have an existing care package in place. The adult can be funding their own care.

In relation to mandatory criteria:

· There is a lack of clarity or consensus about the cause of the adult’s death (e.g. SAB members may feel it is advantageous to wait for the outcome of the coroner’s inquest for the cause of death to be determined).

Points for discussion

· The Care Act does not require that a specific physical or medical cause has been proven, however it does require that we should either know or suspect that the death resulted from abuse or neglect (Care Act 2014, section 44, 2).

· It is important to minimise delay in gaining learning and improvement. The statutory guidance on SAR timeframes advises that (chapter 14.173) “the SAB should aim for completion of a SAR within a reasonable period of time and in any event within 6 months of initiating it, unless there are good reasons for a longer period being required; for example, because of potential prejudice to related court proceedings”. 

· There is a lack of clarity or consensus about whether what happened to the adult would be regarded as abuse or neglect.

Points for discussion

· The Care Act 2014 statutory guidance chapter 14.16 advises that “local authorities should not limit their view of what constitutes abuse or neglect, as they can take many forms and the circumstances of the individual case should always be considered”. Categories to include are physical abuse, domestic abuse, sexual abuse, psychological abuse, financial abuse, modern slavery, discriminatory abuse, organisational abuse, neglect and acts of omission, and self-neglect.

· Feedback from several SABs was that they would not regard self-harm or suicide to be forms of abuse or neglect, but would still be interested in monitoring data about these forms of harm as part of their wider data-set to inform strategy and prevention work.

In relation to discretionary criteria:

· There have already been recent SARs or other sources of local learning exploring the particular practice or systems issues.

Points for discussion

It is important to draw on local data to inform your judgements about which cases would be most useful to commission a discretionary SAR. If the area of practice is already well understood then it will be more proportionate to avoid re-exploring this.