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Identify Factors Which Have Featured in Reports into Serious Cases of Abuse and Neglect

This page is designed to answer the following questions:

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There have been several high-profile cases of abuse and neglect that you may have heard of or followed in mainstream media such as Winterbourne View, Stafford Hospital and Orchid View Care Home.

Investigations into these cases after-the-fact are performed by Safeguarding Adults Boards (SABs) in the form of Safeguarding Adults Reviews (SARs). These SAR reviews (previously known as Serious Case Reviews) uncovered a range of failings in the safeguarding of adults – some of the main factors were:

  • poor or non-existent communication between and within agencies and poor partnership working
  • lack of person-centred approaches e.g. the individual receiving care and their family were not involved in decisions about their care
  • failure to identify and/or report signs of abuse
  • little or no management support or presence
  • poor staff recruitment processes
  • poor staff training and development (especially around safeguarding)
  • staff fear of retribution for whistleblowing

It is important to understand where things have gone wrong in the past to ensure that mistakes are not repeated going forward.

It is also important that care workers have adequate training to recognise the symptoms of abuse, understand the systems and processes for reporting abuse (including whistleblowing policies) and have the courage to report any concerns that they have.


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