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Serious case review was neither envisaged nor mandated in the original No Secrets (Department of Health, 2000) although individual authorities have issued protocols in the intervening period. Recognising that there would always be a need to look back and to learn from challenging cases, Kent was one of the first authorities to put in place a mechanism for referral and conduct of these reviews. In this paper, I summarise the way this process is set in train, and what we have learned from the reviews we have undertaken to date. I write as the independent chair of the Serious Case Review Panel, and as an occasional chair of one‐off inquiries for other authorities, which I also refer to for comparison.

This paper reviews the progress that Cornwall County has made since the murder of Steven Hoskin and the resulting Serious Case Review (Flynn, 2007). Interviews were held with senior and frontline personnel, whose agencies were in contact with Steven and the people who moved into his bedsit. The agencies have progressed significantly, in terms of attitude and reforming the way in which they work. The outcomes and processes that have resulted from the action plans that were drawn up have been welcomed, although there are still challenges to overcome.

This paper originates from accessing the Cornwall Council website (Cornwall Council, 2010) in order to download the report of the serious case review into the murder of Steven Hoskin for teaching purposes on a Post‐Qualifying Social Work programme. However, there were another two serious case review reports posted, which were also relevant to the course. This reflective piece follows from a reading of the executive summary of one of them ‐ the Serious Case Review report into the death of JK (a 76‐year‐old female) in 2008 in Cornwall (Cornwall & Isles of Scilly Safeguarding Adults Board, 2009). While adult safeguarding is everybody's business, because of the original reason for accessing the report, the paper approaches the issues primarily from a social work perspective.

The purpose of this paper is to draw on systemic and psychodynamic theories to subject published serious case reviews (SCRs) involving self-neglect to a deeper level of scrutiny, in order to understand how complex contexts impact on self-neglect work. It also updates the dataset of self-neglect SCRs and accompanying thematic analysis.

Psychodynamic and systemic ideas are applied to the content of published SCRs in order to understand how different contexts – societal, legal, organisational, professional and personal – impact on and are influenced by work with adults who self-neglect. Further published reviews are added to the core dataset, with thematic analysis updated using four domains.

Thematic analysis within and recommendations from SCRs have focused on the micro context, what takes place between individual practitioners, their teams and adults who self-neglect. This level of analysis also commonly extends to how organisations have worked together and how Local Safeguarding Adults Board (LSABs) have supported and scrutinised their collaboration. This level of analysis enables an understanding of local geography. However, there are wider systems that impact on and influence this work, especially law and the societal context. If review findings and recommendations are to fully answer the question why, systemic analysis should be extended to appreciate the influence of national geography.

There is still no national database of reviews commissioned by LSABs so the dataset reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in LSAB annual reports. This makes learning for service improvement challenging.

Answering the question why is a significant challenge for safeguarding adults reviews (SARs). Different approaches have been recommended, some rooted in systems theory. The theoretical formulations here extend the lens of systemic analysis on the different contexts that influence how practitioners work with adults who self-neglect and simultaneously are shaped by that work. This adds to the practice, management and organisational evidence base for working with adults who self-neglect but also shines the analytic lens on legal and policy mandates.

The paper extends the use of systemic theory for understanding and learning from practice with adults who self-neglect and additionally offers psychodynamic formulations to appreciate what happens within and between practitioners and their organisations. The paper therefore contributes new perspectives to the methodology for conducting SARs. It also extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice.

The purpose of this paper is to analyse in detail the findings from 40 serious case reviews (SCRs) involving adults who self-neglect, and to consider the commissioning and reporting of such inquiries in the context of accountability that also involves the Coroner and the Local Government Ombudsman.

This study comprised a cross-case analysis of 32 SCRs, using a four-layer design of the adult and their living context, the team around the adult, the organisations around the team, and the Local Safeguarding Board around the organisations.

Available reports tend towards description of events rather than appraisal of what influenced practice. They highlight the challenges in cases of self-neglect practice, including person-centred approaches, capacity assessment and securing engagement. Familiar themes emerge when the spotlight turns to professional and organisational networks, namely information-sharing, supervision, recording and compliance with procedures and legal rules. Some Local Safeguarding Adults Boards found the process of conducting and then using serious case reviews for service improvement challenging.

The cross-case approach to thematic analysis focuses on reports into situations where outcomes of professional and organisational intervention had been disappointing. Nonetheless, the themes derived from this analysis are similar to other research findings on what represents best practice when working with cases involving self-neglect.

The paper identifies learning for the effective commissioning and conduct of SCRs, and for service improvement with respect to practice with adults who self-neglect.

The paper offers further detailed analysis of a large sample of SCRs that builds the evidence-base for effective practice with adults who self-neglect and for efficient management of process of commissioning and conducting SCRs.

The purpose of this paper is to report the findings from research into 40 serious case reviews (SCRs) involving adults who self-neglect.

The study comprised analysis of 40 SCRs where self-neglect featured. The reviews were found through detailed searching of Local Safeguarding Adult Board (LSAB) web sites and through contacts with Board managers and independent chairs. A four layer analysis is presented of the characteristics of each case and SCR, of the recommendations and of the emerging themes. Learning for service improvement is presented thematically, focusing on the adult and their immediate context, the team around the adult, the organisations around the team and the Local Safeguarding Board around the organisations.

There is no one typical presentation of self-neglect; cases vary in terms of age, household composition, lack of self-care, lack of care of one's environment and/or refusal to engage. Recommendations foreground LSABs, adult social care and unspecified agencies, and focus on staff support, procedures and the components of best practice and effective SCRs. Reports emphasise the importance of a person-centred approach, within the context of ongoing assessment of mental capacity and risk, with agencies sharing information and working closely together, supported by management and supervision, and practising within detailed procedural guidance.

There is no national database of SCRs commissioned by LSABs and currently there is no requirement to publish the outcomes of such inquiries. It may be that there are further SCRs, or other forms of inquiry, that have been commissioned by Boards but not publicised. This limits the learning that has been available for service improvement.

The paper identifies practice, management and organisational issues that should be considered when working with adults who self-neglect. These cases are often complex and stressful for those involved. The thematic analysis adds to the evidence-base of how best to approach engagement with adults who self-neglect and to engage the multi-agency network in assessing and managing risk and mental capacity.

The paper offers the first formal evaluation of SCRs that focus on adults who self-neglect. The analysis of the findings and the recommendations from the investigations into the 40 cases adds to the evidence-base for effective practice with adults who self-neglect.

Serious case reviews (SCRs) are one means of learning the lessons arising from adverse, salient incidents and tragedies. Adult Safeguarding Boards in England are expected to have an SCR policy and procedure, to commission SCRs, to abstract and act on the learning, and to monitor the resulting action plans.

Since SCRs reflect a wide range of processes, the authors undertook a general review, drawing on their experiences of conducting and contributing to SCRs. They chose to pose sets of question‐prompts regarding the commissioning process, the management of the process, the appointment of a chair and author, the terms of reference, information‐sharing, confidentiality, involving relatives and making findings public. The compliance of the process with human rights legislation is also considered.

Whilst the authors acknowledge the responsibility of organisations to promote continuous and cumulative professional learning, they do not promote SCRs as the sole means of learning about the ways in which professionals and agencies work together to safeguard adults at risk of abuse.

The paper challenges the perception that SCR can be streamlined, structured, codified, and constrained.

The purpose of this paper is to consider the importance of professional curiosity and partnership work in safeguarding adults from serious harm, abuse and neglect.

The paper draws on a range of materials including: review of published materials in relation to professional curiosity, reports from adult serious case reviews (SCRs) and safeguarding adult reviews (SARs); relevant materials drawn from the SAR Library, thematic reviews of SARs and Google searches; observations from practice and experience. It also refers to the relevant academic literature.

Lessons from SCRs and SARs show that a lack of professional curiosity and poor coordination of support can lead to poor assessments and intervention measures that can fail to support those at risk of harm and abuse. There are a number of barriers to professionals practicing with curiosity. Working in partnership enhances the likelihood that professional curiosity will flourish.

There are clear implications for improving practice by increasing professional curiosity amongst professionals. The authors argue that there is a scope to improve professional curiosity by utilising and developing existing partnerships, and ultimately to help reduce the number of deaths and incidents of serious harm.

The paper considers the importance of employing professional curiosity and partnership work in safeguarding adults’ practice, so enabling practitioners to better safeguard adults at risk of abuse and neglect.

Serious Case Reviews (SCRs, now Safeguarding Adults Reviews (SARs)) may be held at local level in England when a vulnerable adult dies or is harmed, and abuse or neglect is suspected, and there is cause for concern about multi-agency safeguarding practice. There has been no analysis of SCRs focussing on pressure ulcers. The purpose of this paper is to present findings from a documentary analysis of SCRs/SARs to investigate what recommendations are made about pressure ulcer prevention and treatment in a care home setting in the context of safeguarding. This analysis is presented in cognisance of the prevalence and risks of pressure ulcers among care home residents; and debates about the interface of care quality and safeguarding systems.

Identification of SCRs and SARs from England where the person who died or who was harmed had a pressure ulcer or its synonym. Narrative and textual analysis of documents summarising the reports was used to explore the Reviews’ observations and recommendations. The main themes were identified.

The authors located 18 relevant SCRs and 1 SAR covering pressure ulcer care in a care home setting. Most of these inquiries into practice, service communications and the events leading up to the death or harm of care home residents with pressure ulcers observed that there were failings in the care home, but also in the wider health and care systems. Overall, the reports reveal specific failings in multi-agency communication and in quality of care. Pressure ulcers featured in several SCRs, but it is problems and inadequacies with care and treatment that moved them to the safeguarding arena. The value of examining pressure ulcers as a key line of inquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what constitutes optimal care and treatment. In the new Care Act 2014 context they may continue to feature in safeguarding enquiries and investigations as they may be possible symptoms of system failures.

Reviews vary in content, structure and accessibility making it hard to compare their approach, findings and recommendations. There are risks in drawing too many conclusions from the corpus of Reviews since these are not published in full and contexts have subsequently changed. However, this is the first analysis of these documents to take pressure ulcers as the focus and it offers valuable insights into care home practices amid other systems and professional activity.

This analysis highlights that it is not inevitably poor quality care in a care home that gives rise to pressure ulcers among residents. Several SCRs note problems in wider communications with healthcare providers and their engagement. Nonetheless, poor care quality and negligence were reported in some cases. Various policies have commented on the potential overlap between the raising of concerns about poor quality care and about safeguarding. These were highlighted prior to the Care Act 2014 although current policy views problems with pressure ulcers more as care quality and clinical concerns.

The value of this documentary analysis is that it rests on real case examples and scrutiny at local level. Future research could consider the findings of SARs, similar documents from the rest of the UK, and international perspectives.

The value of having a set of documents about adult safeguarding is that they lend themselves to analysis and comparison. This first analysis to focus on pressure ulcers addresses wider considerations related to safeguarding policy and practice.

The purpose of this paper is twofold: first, to update the core data set of self-neglect serious case reviews (SCRs) and safeguarding adult reviews (SARs), and accompanying thematic analysis; second, to respond to the critique in the Wood Report of SCRs commissioned by Local Safeguarding Children Boards (LSCBs) by exploring the degree to which the reviews scrutinised here can transform and improve the quality of adult safeguarding practice.

Further published reviews are added to the core data set from the websites of Safeguarding Adults Boards (SABs) and from contacts with SAB independent chairs and business managers. Thematic analysis is updated using the four domains employed previously. The findings are then further used to respond to the critique in the Wood Report of SCRs commissioned by LSCBs, with implications discussed for Safeguarding Adult Boards.

Thematic analysis within and recommendations from reviews have tended to focus on the micro context, namely, what takes place between individual practitioners, their teams and adults who self-neglect. This level of analysis enables an understanding of local geography. However, there are other wider systems that impact on and influence this work. If review findings and recommendations are to fully answer the question “why”, systemic analysis should appreciate the influence of national geography. Review findings and recommendations may also be used to contest the critique of reviews, namely, that they fail to engage practitioners, are insufficiently systemic and of variable quality, and generate repetitive findings from which lessons are not learned.

There is still no national database of reviews commissioned by SABs so the data set reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. This makes learning for service improvement challenging. Reading the reviews reported here against the strands in the critique of SCRs enables conclusions to be reached about their potential to transform adult safeguarding policy and practice.

Answering the question “why” is a significant challenge for SARs. Different approaches have been recommended, some rooted in systems theory. The critique of SCRs challenges those now engaged in SARs to reflect on how transformational change can be achieved to improve the quality of adult safeguarding policy and practice.

The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also contributes new perspectives to the process of conducting SARs by using the analysis of themes and recommendations within this data set to evaluate the critique that reviews are insufficiently systemic, fail to engage those involved in reviewed cases and in their repetitive conclusions demonstrate that lessons are not being learned.