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Single Unified Safeguarding Review: Draft Statutory Guidance

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Single Unified Safeguarding Review: Draft Statutory Guidance

June 2023


The role of the independent Older People’s Commissioner for Wales (OPCW) is to protect and promote the rights of older people living in Wales. The Commissioner routinely scrutinises those policies and practices, with the potential to impact the rights of older people.

Stopping the abuse of older people in Wales is a key priority for the Commissioner. In 2020, the OPCW established a ‘Stopping Abuse Action Group’ (overseen by a ‘Stopping Abuse Steering Group’), to help ensure that older people at risk of, or experiencing abuse, were afforded increased protection throughout the Covid-19 pandemic [i]. Through collaborative working, the members of these groups developed a six-level strategy for ending the abuse of older people in Wales [ii]. Improving the practice of front-line professionals through improved training and education, is a significant part of this overall strategy.


Existing Adult Practice Reviews (APRs) provide vital opportunities for organisational reflection and learning. Recent research seems to favour the amalgamation of currently separate APRs, Domestic Homicide Reviews (DHRs) and Mental Health Homicide Reviews (MHHRs) [iii] [iv]. However, much of the success of the new ‘Single Unified Safeguarding Review’ (SUSR) process, inevitably depends upon the clarity of the accompanying statutory guidance. The Commissioner is therefore pleased to respond to this consultation upon the draft statutory guidance. The comments made within this response, follow the numbering of the questions within the consultation document.


Questions 1 and 2 (related to the aims and reasons for producing the Single Unified Safeguarding Review (SUSR) process, and its underlying principles).

The guidance provides a clear rationale for developing the SUSR process. Drawing upon recent research, the guidance states that the combined review will reduce the complexity of existing separate, review processes. It is also argued that the SUSR will increase opportunities for practitioner and organisational learning and will promote interdisciplinary tolerance and understanding.

Significantly, the guidance highlights the ways that individuals and families will potentially benefit from a combined review process. Many family members will find engaging with review processes, extremely challenging. When contributing to reviews, the risk of re- traumatisation is very real; some family members will inevitably ‘re-live’ aspects of their experience as they engage with reviewers and share their perspectives on past situations and events. The risk of re-traumatisation is increased when families are engaged in multiple review processes; particularly where information is not shared across separate reviewing bodies.

The SUSR is underpinned by positive principles. The focus upon person-centred and relationship-based practice, is particularly important. It is pleasing to see that the guidance recognises the challenges of safeguarding work and acknowledges the importance of developing supportive working environments for front-line practitioners.


Questions 3, 4 and 5 – focused on the clarity of the guidance in relation to eligibility, process and the roles and responsibilities of reviewing bodies.

Combining separate reviews into one single, unified review process is an ambitious, complex, and challenging task. It is therefore critical that the statutory guidance is as clear and concise as possible.

The wording of the guidance around eligibility, process, and the roles and responsibilities of various members, should be simplified to effectively direct the work of Regional Safeguarding Boards (RSBs). Clarity is essential to ensure that the eligibility criteria for the SUSR is consistently applied across geographical areas. It is also vital to ensure that respective bodies fully understand their various respective roles and responsibilities within the SUSR process.

Elements of the draft guidance are complex, making it difficult to read and comprehend at times. The separate reviews are currently accompanied by their own pieces of practice guidance. These various practice guidance documents outline, in turn, the criteria for review eligibility in significantly different ways. So, for instance, the guidance related to MHHR is prescriptive in stating that a review should be undertaken if a Local Authority has had “contact” (has undertaken either a “assessment” or engaged in “intervention”) with an individual within the last year. The guidance around APRs refers to “action” but does not define this (does this only refer to situations within which practitioners have been involved in active interventions or would this also include assessment?). The guidance for APR states that a review must be undertaken if the Local Authority had been involved with an individual and family within the preceding six months. It may be difficult for RSBs to reconcile the requirements of these different pieces of guidance, with the result that the eligibility criteria for SUSR is inconsistently applied. The guidance for undertaking APRs also distinguishes between “concise” and “extended” reviews, based on levels of Local Authority engagement. This distinction does not appear in the guidance for either the DHR or the MHHR, which again, potentially complicates the process of determining eligibility.

The guidance might read more easily if it was written as a ‘stand-alone’ document. At the moment, there are multiple references to other pieces of guidance and documentation, which makes reading and comprehension difficult and time-consuming. It is essential that the guidance functions as a single, accessible resource for RSBs and others; a document to which organisations can turn, to quickly resolve practice issues and uncertainties.

Some of the language used within the draft guidance is ambiguous and is not therefore appropriate to statutory guidance. For example, the reference made to the chair of the RSB giving “due regard” to the Chair of the Community Safety Partnership in situations where the review involves a Domestic or Offensive Weapon Homicide (pg. 27 of the guidance), should be amended. The phrase “due regard” does not make clear the responsibilities of the RSB within such situations and is not helpful in determining the extent to which the perspectives of the Chair of the Community Safety Partnership, should be incorporated into overall decision-making. A lack of clarity around roles and responsibilities is likely to result in tension between organisations and will limit opportunities for interdisciplinary reflection and learning.

It also seems that certain parts of the guidance are not yet complete; this makes it difficult to provide a full response to the consultation. For example, reference is made to a ‘single unified safeguarding review toolkit’, to be accompanied by an information leaflet. Whilst a standardised leaflet may be helpful, this does not appear to be included in the current guidance.


Questions 6 and 7, referring to the guidance around involving community partners, and requests for information from ‘qualifying persons or bodies’.  

To ensure that opportunities for organisational learning are maximised, it is critical that RSBs consider the circumstances of individuals and families as fully and holistically as possible. It is therefore helpful to have a list of possible community partners who might input into the review process. If RSBs are to approach the right community partners they must, of course, acquire a full understanding of a person’s biographical history; their personality and preferences. Such understanding demands that RSBs engage fully with those closest to an adult at risk (such as family members and friends).


Question 9. Refers to the guidelines for engagement with victims, families, and principal individuals.

Involving families in review processes is critical to reviewers fully understanding the circumstances of adults at risk (as above) and is often important to family members themselves. The Commissioner offers an Advice and Assistance Service. Some family members have contacted the Advice and Assistance Service, to discuss the support provided by public bodies in situations where older people have experienced abuse or neglect. They have said that what matters to them in situations where older people have experienced abuse, is that lessons are learned, and that future practice is improved. The wish of such families is that others are spared the distress of similar challenging circumstances.

The guidelines around engagement are comprehensive. It is positive that careful consideration has been given to styles of communication (sensitivity and inclusivity, for example), and that the guidance clearly reflects the emotional impacts of engaging with review processes, from a victim and family perspective.

Although advocacy is mentioned, there should be a greater focus on the advocacy available to victims and family members. Some older people and families may find it very difficult to engage with public bodies, and to participate in complex review processes. Increasing access to advocacy might strengthen such involvement. It is important, therefore, that victims and families are offered advocacy as a matter of course. The guidance should clearly reflect the responsibility of RSBs in this respect.

Reference is made to the need for creativity when engaging with children and young people.  The same consideration should be given to promoting creative methods of communication with certain groups of older people. It is sometimes assumed that certain groups of older people are unable to engage within assessment and review processes, because of issues around mental capacity (older people with dementia, for example). Research shows however, that many older people with dementia (even those within the more progressive stages of the illness), can share their experiences and perspectives with practitioners, when methods of communication are creative and adaptable[v]. It is vitally important that older people are not excluded from inputting into SUSR processes, simply because assumptions are made regarding their capacity for engagement based on a diagnosis of illness.

The guidance refers to a “Victims and Family Reference Group”, which will “provide a forum for the victim and family voice across Wales to inform the delivery of the Single Unified Safeguarding Review and its national governance and oversight work”. Whilst the development of such a group appears positive in principle, it would be helpful to know how members will be recruited, renumerated, and supported. Consideration must be given to the sorts of actions needed to ensure that this group is demographically representative, and to ensure that it incorporates the voices of older people and their families.

It is important that reference is made to complaint’s processes and as stated within the guidance, victims and families must be made fully aware of the procedures for raising concerns in relation to the review process.


Question 14. What in your view would be the likely impacts upon individuals and groups with protected characteristics of the ways of working set out in this guidance? Your views on how positive effects could be increased, or negative effects could be mitigated, would also be welcome. Please use the text box to explain your reasoning.

The guidance appropriately recognises the need for cultural sensitivity within the SUSR process. It is extremely important, for example, that victims and families have access to reviewers with an in-depth knowledge of their specific cultural backgrounds. Such knowledge is critical to recognising the ways within which specific aspects of an individual’s cultural experience, may have influenced a certain series of events. Processes for engaging with and feeding back to victims and families should also be culturally sensitive and as stated within the guidance, RSBs should communicate with individuals and families in the language of their choice.

The guidance refers to RSBs holding lists of appropriately qualified reviewers. It would be helpful to understand the measures to be taken, to ensure appropriate levels of cultural diversity among reviewers. What steps will be taken where it is not possible to ensure cultural diversity? How will any limitations be overcome?

Older people are not a homogenous group, and the review process must be undertaken with the highest levels of cultural sensitivity, knowledge and understanding. Research undertaken by the OPCW, shows that older people from black, Asian and minority ethnic backgrounds and, for example, from LGBTQ+ communities are at heightened risk of abuse and neglect [vi]. Older people from these groups often find it extremely difficult to access the support they need. Statistics show that the likelihood of men experiencing abuse increases with age [vii]. Recent research commissioned by the OPCW shows that when older men experience domestic abuse, they face additional challenges in seeking service provision [viii]. Some professionals have been found to make assumptions around the nature of abusive relationships (assuming that men are the perpetrators of abuse and women are the victims). Such assumptions increase the difficulties experienced by older men when seeking support to flee their abusive relationships.

Members of RSBs should be alert to the ways within which the presence of protected characteristics, potentially increase a person’s vulnerability to abuse. When a review finds that an individual’s protected characteristics have contributed to their experiences of abuse, this should be explicitly drawn out and discussed within practitioner learning events.


Question 15 relates to the likely impacts of the ways of working, set out in the guidance.

In working in accordance with the guidance, RSBs face a far greater volume of work. It is essential that the current opportunities for learning and improving practice with older people, offered through APR processes, are not lost as these reviews are combined with others in the SUSR process. It is important to know what additional resources RSBs may be offered, to ensure that they are able to carry out their work effectively and to maximise the potential for learning through the SUSR process. What support will be made available to RSBs as they transition to the new SUSR process e.g., additional training?

The creation of a repository to collate learning from past reviews is positive. However, opportunities for learning will not be maximised unless practitioners and organisations have the time to attend learning events, and to properly absorb and to reflect upon key messages and themes. It is essential that issues of workforce recruitment and retention are addressed, to ensure the availability of time for practitioner learning.

Question 16 and 17 relate to the impacts of the SUSR process on the Welsh language

It is critically important that victims and families can engage with the review process in the language of their choice. Language is a source of distinction and identity and is therefore, a fundamental element of a personalised approach to care [ix].  At times of emotional stress, older people can find it far easier to describe their situations and to talk about their fears, anxieties, and options for support in their ‘first language’.  There will need to be sufficient Welsh speaking reviewers to ensure that reviews are undertaken through the medium of Welsh if this is the wish of victims of families.  Action will need to be taken to address any limitations in resource in this area.


[i] Older People’s Commissioner for Wales. Stopping Abuse Action Group. Available at: Stopping Abuse Action Group – Older People’s Commissioner for Wales

[ii] Older People’s Commissioner for Wales: Strategy to End the Abuse of Older People. Available at: Stopping Abuse Action Group – Older People’s Commissioner for Wales

[iii] Robinson, A.L., Rees, A. and Dehaghani, R. 2019. Making Connections: A Multidisciplinary Analysis of Domestic Homicide, Mental Health Homicide and Adult Practice Reviews. The Journal of Adult Protection 21(1), pp. 16-26.

[iv] Rees, A. Dehaghani, R.., Slater, T. and Swann, R. 2021. Findings from a Thematic Analysis of Adult Practice Reviews in Wales. Available at: Findings from a thematic analysis of Adult Practice Reviews in Wales – Safeguarding Board Wales

[v] Sherwin, S. and Winsby, M. 2010. A Relational Perspective on Autonomy for Older Adults Residing in Care Homes. Health Expectations 14(2), pp. 182-190.

[vi] Older People’s Commissioner for |Wales. 2021. Support Services for Older People Experiencing Abuse in Wales. Available at: Support_Services_for_Older_People_Experiencing_Abuse_in_Wales.pdf (

[vii] Office for National Statistics 2022. Domestic Abuse in England and Wales Overview (November 202):
Domestic abuse in England and Wales Overview. Available at:

[viii] Older People’s Commissioner for Wales. 2022. Improving Support and Services for Older Men Experiencing Domestic Abuse. Available at: Improving-support-and-services-for-older-men-experiencing-domestic-abuse.pdf (

[ix] Madac-Jones, I. and Dubberley, S. 2005. Language and the provision of health and social care in Wales. Diversity in Health and Social Care (2), pp. 127-134.

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