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
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 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