Learning Reviews

This report is a joint national overview of learning review activity. Data in this report is drawn from learning review notifications from 19 adult protection committees (APCs) and 15 child protection committees (CPCs).

During the reporting periods, fifteen learning review reports were submitted to the Care Inspectorate for children and young people and thirteen for adults.

This is an ASPire webinar from August 2025. Its theme is sharing positive case studies and strength-based practice in Adult Support and Protection. It has sessions from Dundee HSCP (on strength-based practitioner reflection); South Ayrshire HSCP (on GIFRE - Getting It Right For Everyone); Stirling & Clacks HCSP (on hearing the family voice in Learning Reviews) and Iriss  (on focusing on the good within ASP Joint Inspection Reports).

Slides for all sessions are also attached.

This report sets out the significant themes found in Adult Support and Protection learning reviews / significant case reviews between October 2022 and November 2023. It includes information regarding notification of learning reviews, reviews the information contained in learning reviews, assesses the impact on practice, and sets out next steps / future recommendations.

An Adult Support and Protection Learning Review is a means for public bodies and office holders with responsibilities relating to the protection of adults at risk of harm to learn lessons from considering the circumstances where an adult at risk has died, or has been significantly harmed. This guidance is for Adult Protection Committees to use when considering, or undertaking, Learning Reviews.

This presentation was delivered in April 2024 to a joint Child Protection / Adult Support and Protection meeting. It explains the significant case review / learning review of Margaret Fleming, who was murdered late 1999/early 2000. The review sought to learn from Margaret's life and explicitly adopts a human rights and trauma-informed approach. The learning disability community were included within the review.

This presentation was delivered by the Care Inspectorate in April 2024 to a joint child protection / Adult Support and Protection meeting. It sets out the background to both children's and adults learning reviews, and themes that can be pulled out from each. The presentation also details the Care Inspectorate developments on aligning processes between children's and adults learning reviews, and future work.

This informal learning review follows a series of crisis meetings that led to the hospital admission of 'A22'. It particularly concerns a whole-family approach to Adult Support and Protection and taking a multi-agency approach in this. Issues discussed include challenges around escalation (when to escalate, to whom, and what to do when no escalation processes exist). Also covered is the challenge when supporting an adult who chooses not to engage - particularly where capacity and choice exists.

This informal learning review is based on a request made by the Mental Welfare Commission (MWC). Issues covered in this review include self-neglect, hoarding behaviour, multi-agency working, chronologies, and professional curiosity.

This informal learning review is based on findings from the 2022 Adult Support and Protection joint inspection in Perth and Kinross. Issues covered in this review include emotionally unstable personality disorder (EUPD), self-harm, multi-agency working, recording, and trauma-informed practice.
 

This video, from the ASPire 2024 conference, sets out the key messages from Adult Support and Protection Learning Reviews. This includes common factors leading to a Learning Review, most prominent types of harm, and how Learning Reviews impact practice. Implications for ASP improvement across Scotland are considered.