Page 28 - Adult C Overview Report - FINAL

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 Take place within a culture of continuous learning and improvement across the
organisations that work together to safeguard and promote the wellbeing and
empowerment of adults, identifying opportunities to draw on what works and promote
good practice;

 Be proportionate according to the scale and level of complexity of the issues being
examined;

 Be led by individuals who are independent of the case under review and of the
organisations whose actions are being reviewed;

 Ensure professionals are involved fully in reviews and invited to contribute their
perspectives without fear of being blamed for actions they took in good faith;

 Ensure families are invited to contribute to reviews. They should understand how they
are going to be involved and their expectations should be managed appropriately and
sensitively.

 Focus on learning and not blame, recognising the complexity of circumstances
professionals were working within;

 Develop an understanding of who did what and the underlying reasons that led
individuals and organisations to act as they did;

 Seek to understand practice from the viewpoint of the individuals and organisations
involved at the time and identify why things happened;

 Be inclusive of all organisations involved with the adult and their family and ensure
information is gathered from frontline practitioners involved in the case;

 Include individual organisational information from Internal Management Reviews /
Reports / Chronologies and contribution to panels;

 Make use of relevant research and case evidence to inform the findings of the review;

 Identify what actions are required to develop practice;

 Include the publication of a SAR Report (or executive summary);

 Lead to sustained improvements in practice and have a positive impact on the outcomes
for adults.

2. Case Summary

Adult C was a 30-year-old lady who died following cardiac arrest after diagnosis and treatment
for pneumonia. Adult C was a longstanding alcoholic who showed some signs of wanting to
reduce her alcohol consumption. Adult C was known to have been in an abusive relationship with
many reports of injuries from both her partner and her ex father in law as well as others. Adult C
was also considered to be a perpetrator of physical violence against her partner and other adults.
Adult C was known to many agencies as a result of her alcoholism and the abuse she suffered. On

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