Serious Risk Prevention in Adult Social Care

Who are Serious Risk Prevention?

Serious Risk Prevention (SRP) is a UK‑based consultancy specialising in risk management for adult social care providers. Their work focuses on real‑world safety challenges that can lead to serious harm or death, not just ticking regulatory boxes, but ensuring that risk controls are effective in practice.

At the helm of SRP is Emma Reeve, who brings over two decades of experience in adult social care, drawn from roles ranging from frontline care delivery to senior leadership. That breadth of experience enables SRP to understand both the operational and strategic dimensions of care provision.

When “we did everything we could” may not be true

In adult social care, the worst days can be brutally similar. For example, a person could choke on food at the dining table that everyone knew was unsafe for them. Someone could be found unresponsive in the bath, with water far hotter than it should have been. A resident could die after days of constipation and silent deterioration; when the coroner reports back, they describe 10 kilograms of faeces removed after death.Night staff could “keep an eye” on a person with epilepsy, but are unable to show when they last checked on them or what they did when their breathing changed. In each of these cases there would have been care plans, policies, training records and risk assessments. On paper, it would have looked as if the provider had “done everything they could.” In reality, the gap between what should have happened and what did happen can cost someone their life.

Serious Risk Prevention was founded to safeguard lives, born from too many experiences of the calls you never want to receive – another preventable death, another catastrophic incident, another team shattered by something that could have been avoided.

The effect on care providers

Whether you support older people, children, people with learning disabilities, autistic individuals, or those with severe mental health needs, the pattern is the same.

NHS England’s review into deaths of people with learning disabilities and autistic people reported that around 39% were avoidable in 2023, with the same themes repeating: choking, constipation and bowel obstruction, failure to recognise deterioration, poor epilepsy management, and failures in observation and escalation.

The message is clear and unavoidable: policies, training and dashboards alone is not enough to prevent these risks.

Serious risk needs serious prevention

When the basics fail, the consequences can be huge, and may involve:

• People suffering avoidable deaths

• Families living with the knowledge it didn’t have to happen

• Staff carrying guilt and trauma for years

• Organisations facing criminal investigation, coroner scrutiny, enforcement action and large civil claims

Unfortunately, no amount of paperwork softens these realities.

The illusion of safety

Most providers can already show:

• A choking policy

• An epilepsy policy

• A bowel care policy

• Bathing and water-temperature procedures

On paper, these look reassuring. Yet when something catastrophic happens and the documentation is pulled apart, the uncomfortable questions that follow are usually very simple:

• Exactly who was at highest risk, and did staff know it that day?

• What control was supposed to be in place, and can you show it was actually delivered on that shift?

• When early signs of deterioration appeared, who noticed, what did they do, and how was that escalated?

Too often the honest answers are:

• We thought everyone knew.

• We assumed it was happening.

• We didn’t realise how serious it was until it was too late.

From a Serious Risk Prevention perspective, a service that “looks good” on paperwork, but is unable to answer those questions confidently, is not safe, it is lucky.

How Serious Risk Prevention can help

Serious Risk Prevention do not simply deliver another generic audit or generate more paperwork. Instead, they shift focus on what you pay attention to and how you can demonstrate that the risks most likely to end up in a coroner’s report or a courtroom, have been managed.

Serious Risk Prevention help organisations to:

• Shift from assumption to demonstrable control – Move from “we’re pretty sure it’s happening” to “we can evidence that the right protections were in place for the right people at the right times.”

• Expose blind spots that standard compliance misses – Expose the uncomfortable gaps where practice has quietly drifted away from policy, especially at busy times, on nights and at weekends.

• Create evidence that stands up to scrutiny – Build a focused set of artefacts that make serious risk assurance inspectable: who is most at risk, what has to happen to keep them safe, and how you know it actually happened last week, not just last year.

The detail of how each provider gets to this point will differ by service, client group and setting but the outcome should be the same: fewer avoidable deaths, fewer catastrophic incidents, and a clearer line of sight from the frontline to the board.

How it works in practice: one SRP pilot

An early Serious Risk Prevention proof of concept at a 54-bed care home for older people with complex needs focused on a small number of serious risk themes.

The work identified:

• Hidden safety gaps – Out of date policy, checks being done less frequently than assumed, and confusion over who was actually responsible for key safety tasks between the service and estates functions.

• Weak links in practice – Clinical advice that did not reliably reach the people preparing food or planning activities, and inconsistent recording that made it hard to prove that early warning signs were recognised and acted on.

• Assurance and reputation issues – Public-facing material carrying regulator branding in a way that risked misunderstanding, and governance routes where agreed actions were not tracked through to completion at senior level.

Within 7 days, the provider had:

• Tightened controls around the highest-harm risks in the home.

• Clarified who was accountable for critical safety checks and how they would be monitored.

• Gained stronger evidence for inspection and external scrutiny through executive report.

• Strengthened the “golden thread” to senior leaders, making serious risk visible and discussable at the right level.

Standard compliance activity had not exposed these issues but Serious Risk Prevention did, and converted them into specific, owned fixes that improved day-to-day safety and reduced regulatory, legal, and reputational exposure.

Serious Risk Prevention’s value before and after an incident

Before an incident:

• Reduces the likelihood of catastrophic harm by tightening control around the risks most likely to be fatal or seriously injure people.

• Helps you focus scarce time and resources where they will make the greatest difference.

• Gives boards, trustees, and senior leaders a more truthful view of where they are genuinely safe and where they are exposed.

After an incident:

Even with the best prevention, things can still go wrong.

When they do, SRP provides a structured way to:

• Stabilise the specific risk area so it is less likely to happen again.

• Organise evidence and learning in a way that supports staff, residents and families through investigation and inquest.

• Demonstrate to regulators, commissioners, and insurers that you are confronting the reality, not simply managing reputational damage.

Final thoughts

When a person dies in your care, the question from families, regulators and your own conscience is usually: “Did you have a policy?” Instead, it may be: “Did you do what was reasonably possible to stop this from happening?” Serious Risk Prevention is about being able to answer “yes” to that question with evidence, not just intention.

If you would like support to build a Serious Risk Prevention approach into your services, you can find out more via www.seriousriskprevention.com or by contacting Emma Reeve at info@emlrconsultingltd.com.