Serious Case Reviews into Dementia Care: An Analysis of Context and Content

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Adult Serious Case Reviews (SCRs) are commissioned by local Safeguarding Boards to investigate how local professionals and agencies worked together to safeguard a vulnerable adult following an incident of abuse, harm or death if the Board identifies concerns about agencies' actions from which lessons may be learned. This paper presents the results of a study undertaken in 2013 analysing Adult SCRs where the person who was at risk of harm, or had been harmed or died, had a dementia. Of the eighty-four SCRs available, fourteen were identified as involving a person with dementia and in a further seven the victim(s) may have had dementia. Discrete themes are presented: the situation of self- or publicly funded residents; the potential of poor care quality in all settings for people with dementia, and by different staff and family carers; the lack of communication with family members; and poor integration of care for people with dementia. The SCRs provide vivid illustrations of the ‘faultlines’ that may exist in dementia support systems. In England, Adult SCRs are moving to a statutory basis under the Care Act 2014 and this paper draws attention to their potential as learning materials in dementia care for commissioners, for social workers and for safeguarding practice.
Original languageEnglish
Pages (from-to)514-553
Number of pages9
JournalBritish Journal of Social Work
Issue number2
Publication statusPublished - 2016


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