'In our experience': Chairing and commissioning Serious Case Reviews in adult safeguarding in England

The article reports findings from an audit of Serious Case Reviews into the death or harm of a vulnerable adult in England. Serious Case Reviews may be undertaken by local authorities in partnership with other agencies. There is little government guidance and practice appears variable. Findings: Interviews were undertaken in 2007 with persons who had been appointed to Chair Serious Case Reviews and with those who commissioned such Reviews or managed the process. The findings confirm the aspiration of such Reviews to be opportunities for learning from mistakes, if any, and to thereby offer greater safeguards for vulnerable adults. In practice however, the conduct of such Reviews may be difficult if there is a lack of cooperation, a lack of resources and if there is little opportunity to share findings and recommendations outside the locality. Application: This study supports the sharing of Serious Case Reviews to encourage learning from mistakes and missed opportunities to safeguard vulnerable adults. It also found agreement among those with experience in such Reviews that greater guidance on conduct and collaboration would be welcome.