A Serious Case Review is a process for all partner agencies to identify the lessons that can be learned from particularly complex or serious Safeguarding Adults case, where an Adult at Risk (Vulnerable Adult) has died or been seriously injured and abuse or Neglect has been suspected. The panel recommends changes to improve practice and services in the light of these lessons. The aim of the process is to learn lessons and make improvements, rather than blaming individual people or organisations. It relies on a spirit of openness to learning, about what went well, as well as what could be improved.