Making decisions on SAR requests
5.1 On receipt of a referral, the NYSAB Governance Team will (a) acknowledge the notification, (b) quality check the referral, and (c) advise the Learning and Review (LAR) sub-group Chair and NYSAB Independent Chair of the referral. If the mandatory criteria for a SAR appear to be met, approval will be sought from the NYSAB Independent Chair to proceed. Once approval is received, an initial chronology will be issued to each partner agency from the NYSAB Governance Team. The purpose of the initial chronology is to collect significant information to inform the discussion on whether the SAR criteria are met.
5.2 Where the SAR referral does not indicate the statutory criteria are met, the NYSAB Governance Team may ask the referrer to provide further information. If on receipt of further information, the SAR referral still appears inappropriate, a discussion will be held between representatives from the LAR to decide whether the recommendation should be to proceed, or to decline the referral. The discussion should, at the very least, involve representation from Health and Adult Services (HAS), North Yorkshire Police, and the Integrated Care System(s). The decision will be communicated to the LAR Chair for approval, before the referrer is informed of the decision and the rationale for it.
5.3 In deciding whether a SAR should be conducted, the LAR must first consider whether there is a statutory obligation to undertake a SAR: using the criteria outlined in paragraphs 3.1. A SAR must be commissioned if there is a statutory requirement to do so.
5.4 A SAR referral will ordinarily be considered at the next available LAR meeting, or within ten working days of all initial chronologies being returned if possible. An extraordinary meeting will be arranged if the next LAR meeting is scheduled beyond this timescale.
5.5 Appropriate scrutiny should be held in relation to the joint chronology when determining whether the statutory criteria are met. If the SAR subject is still alive, consideration should be given to their views and experiences when determining whether they have suffered significant harm.
5.6 Consideration should be given to whether other quality assurance and feedback sources (eg audits/complaints) suggest the kind of practice issues in the referral are new, complex or repetitive. If any of the issues and the system conditions indicated in the referral are relevant to the SAB strategic plan, this will be escalated at the earliest opportunity.
5.7 If there is a difference of opinion about whether or not a referral is to be commissioned as a SAR, and a recommendation cannot be reached by consensus, a majority vote will be made and the NYSAB Independent Chair will have the casting vote/decision.
5.8 The recommendation will be forwarded to the NYSAB Independent Chair for ratification. The referrer will be notified of the outcome by a member of the HAS Governance Team using Appendix 3.
5.9 If the LAR considers the threshold is NOT met, but there will be benefit in conducting some form of review, they will consider what type of ‘review’ process will promote effective learning and improvement action to prevent deaths or serious harm occurring in the future. These reviews can provide useful insights into the way organisations are working together to prevent and reduce the abuse and neglect of adults in North Yorkshire. In considering whether there are sufficient lessons to be learned and value in commissioning a Discretionary SAR, LAR will use the guidance shown in Appendix 4.
5.10 The LAR can make the following decisions where the statutory criteria for a SAR are NOT met:
- No further action
- A review which might include a learning event, either a discretionary SAR or a short briefing material highlighting key lessons to be learned or a case file audit (learning review), where this is reasonable and proportionate
- A management review (within one or more organisations, i.e. a Multi Agency Review or a Single Agency Review)
- Rapid Review Process
5.11 The findings of any single or multi-agency review will be shared with the LAR once complete.
5.12 The LAR should also consider whether another review or learning process has already commenced that would identify and share lessons to be learned, or which NYSAB could potentially feed into to avoid duplication (eg Domestic Homicide Review [DHR], Learning Disabilities Mortality Review [LeDeR], Independent Office for Police Conduct [IOPC] investigation or a Serious Incident process). It will be important to provide clarity about any governance issues if other processes are involved. For example, police investigations or an NHS Serious Incident review. If a person has died, the NYSAB Governance Team will contact the Coroner to identify whether an inquest has or will be held.
5.13 Should the referrer challenge the decision of the LAR, the Independent Chair of the NYSAB will respond. The decision can be re-visited if new information has come to light. Any challenge to the decision should be made in writing to the Independent Chair of the NYSAB or NYSAB Governance Team within 28 days of the feedback being received.
5.14 The LAR is responsible for keeping a record of all cases that have been referred and considered for a SAR.
View all our news