Lessons from Serious Case Reviews: What Care Providers Must Act On

Serious case reviews — now increasingly referred to as Safeguarding Adults Reviews (SARs) and Learning and Improvement Reviews — exist for one purpose: to ensure that when things go wrong in health and social care, the whole system learns.

Too often, the learning stays within the organisation where the harm occurred. The themes repeat. The same failures emerge in review after review. And people continue to be harmed in ways that were, in retrospect, preventable.

This article draws together three areas generating significant national attention right now, and sets out the practical actions every health and social care provider should be taking in response.

Following the conviction of neonatal nurse Lucy Letby, NHS England and the Department of Health have been examining the case for mandatory CCTV in neonatal and special care baby units (SCBUs). Multiple independent reviews have highlighted that covert harm in clinical settings can go undetected for extended periods when oversight relies solely on staffing ratios and peer observation.

The emerging consensus from reviews is that CCTV — when implemented with appropriate governance, consent frameworks, and data protection safeguards — can serve as an important additional layer of oversight. Providers operating neonatal or paediatric services should review their current surveillance and oversight policies, engage with NHS England guidance as it develops, and ensure robust escalation and whistleblowing cultures are embedded.

A number of recent NHS investigations and serious case reviews have also highlighted a persistent and serious problem: NHS staff accessing patient records they have no clinical reason to view. Accessing records without a legitimate clinical reason is a serious breach of patient confidentiality and data protection law, and can result in disciplinary action, referral to professional regulators, and in serious cases, criminal prosecution.

Safeguarding Adults Reviews across England have highlighted recurring themes: failure to escalate concerns, inadequate risk assessment, poor information sharing between agencies, workforce pressures masking risk, and lack of professional curiosity. Each of these is preventable with the right training, supervision, and governance frameworks in place.

MDT Online provides bespoke safeguarding training, supervision support, and HR consultancy for health and social care providers. If the themes in this article have raised questions about your organisation's practice, we would welcome a conversation.