Implementing the Significant Incident Learning Process (SILP)

Heather PickAssistant DirectorPersonal Care and SupportLeicestershire County Council

Heather.Pick @leics.gov.uk

Helen PearsonBoard OfficerLeicestershire and Rutland Safeguarding Adults and Children Board

helen.pearson@leics.gov.uk

Pilot Project BackgroundEast Midlands Joint Improvement Partnership

Safeguarding and Dignity Board reviewed Serious Case Review function and process :

Concerns that SCR’s are not always used effectively No standardised practice/lack of consistencyTime consuming and resource heavyQuality of IMRs varyLessons learnt not always disseminated in a timely fashionMuch of the process can be remote from frontline practice, lessons get lost

Commissioning Tools and

Templates

Quality Assurance Framework for Benchmarking Standards in the

Commissioning andDelivery of the East Midlands

Safeguarding Board for conducting SCR’s and SILP’s in the region

PROJECT OUTCOME 1

Project Outcome 2 SILP Pilot Process

Facilitate a ‘live’ SILP process Evaluation of process and learning

outcomes Inform on any required changes to the

process Cost analysis Lessons for all on a new process

SILP Criteria 1. Where an adult who may have been in need of

safeguarding dies or experiences serious harm where this is not due to direct abuse but there is evidence of self- neglect and/or refusal of service AND there may be concerns about their capacity to self- care and understand the consequences of not doing so.

2. Multiple incidents or concerns with increasing frequency and severity within an institutional setting or involving the same provider agency.

3. Serious harm and/or abuse was likely to occur but has been prevented by good practice.

4. Where there are seen to be high levels of public or media interest in an incident

Aims of the SILP

Learn and own lessonsOpenness and critical analysisIndividual and organisational

practiceWhy decisions were made and

actions taken/not taken. Address changes to practiceConsider how changes will happenSMART recommendations

What SILP is not……

SILPs are not inquiries into how a vulnerable adult died or was harmed or who is culpable - that is a matter for Coroners and criminal courts

SILPS are not a part of any disciplinary enquiry or process

Managing the SILP process

No legislative framework No statutory timescales Shared Learning Experience New experience for all services

SILP Process

SILP CASE Background

Two Learning Disabled adult males Sexual assault by one against another

in the toilet. College setting – Adult Education class Perpetrator supported by PA employed

by parent.

Those involved Police MAPPA Adult Social Care – Learning Disability

Team Community Opportunities Health Learning Disability Nursing

Services Adult Learning

Learning from SILP Adult Ed -changes to course enrolment forms Community Ops Project – Poster for notice

board Training for Police re Learning Disabled adults

as alleged perpetrators Recording of sexually inappropriate behaviour

( clarity and transition child-adult) Adult Social Care – responsibility for sharing

information to PA’s Clarified issue of access to Psychological

service during investigation process

Learning – Pilot and subsequent SILPPositive process for those involved if:Address hopes and fearsTiming of SILP ( other process)Getting the right people involvedEnsuring all contributions are obtained and valued at eventsConsider how to involve subject/familyCombined Chronology ( time line /key events)Agreeing lessons learnedConfidentialityCostSkilled Facilitators