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when a serious case review takes place the main aim is to learn lessons also to prevent similar tragedy’s happening again in the future . This is done by strengthening and improving multi agency practices and procedures. Serious case reviews (SCR) are conducted by the English adult protection or safeguarding boards at a local level , this process happens when harm or death has occurred . when promoting better safety and protection all staff ans professionals need to be aware of and learn from previous mistakes ,incidents or even near misses. SCR are not about pointing the finger of blame , but rather to establish if there are lessons to be learnt from the circumstances of the case and how as professionals work together to safeguard vulnerable adults.
In the case of Park fields care home resulting in the conviction of the registered manager Rachel Baker who was found guilty of manslaughter and also preventing the course of justice . A extensive police investigation was conducted after a staff member raised concerns back in Jan 2007 .
The investigation covered the care of ten elderly people. During the serious case review all organisations were represented at seniour level while the review panel was charred by an independent person. The report covered four main elements.
Good practice
Lessons that have been learned
Changes in policy since the events
Recommendations for action to improve adult safeguarding further
Although improvements have been made since concerns were initially raised the report stated even if they had been in place at the time of incidents there was no guarantee that the managers behavior would of come to light because the policy’s and procedures were designed to identify poor working practice incompetence and Independence and poor management, not designed to identify deliberate criminal behavior.
The report suggests concerns need to be pursued effectively but not to impede the delivery of good care that is responsive and person centered.
The report made 21 recommendations for action that was believed to improve safeguarding that all agency’s had to respond to the recommendations.

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