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Safeguarding Adults Reviews

A Safeguarding Adults Review (SAR) is held when an adult with care and support needs has died or suffered serious harm, and there are concerns that abuse or neglect may have been a factor. This was introduced under the Care Act 2014 and was previously known as a Serious Case Review.

The SAR aims to identify and share lessons learned to prevent similar abuse or neglect happening again. It is not the job of the review to redo the investigation or assign blame to any organisation or partners. These reviews are about learning together and improving how adults are protected from abuse. You can read the reports below.

2025

  • 2024

  • 2021

2020

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2018

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2014

2025

  • 2024

  • 2021

2020

2019

2018

2017

2016

2015

2014

Surrey SAB - Safeguarding Adult Review (Executive Summary) - Eddie, August 2024

Surrey Safeguarding Adults Board (SSAB) commissioned this review due to concerns that organisational neglect contributed to his death, findings which have subsequently been made by the coroner. 'Eddie' was a care-experienced 18-year-old, who tragically died in 2019 from diabetic ketoacidosis.

Warrington SAB - Safeguarding Adult Review (Executive Summary) - Laura, November 2020

Gloucestershire Safeguarding Adults Board extends our full sympathies to Laura’s family. Whilst this Safeguarding Adult Review was undertaken by Warrington SAB, we accept the findings of their report and wish to provide further assurance that our partnership is committed to learning from her tragic death.  

Surrey SAB - Safeguarding Adult Review (Executive Summary) - Eddie, August 2024

Surrey Safeguarding Adults Board (SSAB) commissioned this review due to concerns that organisational neglect contributed to his death, findings which have subsequently been made by the coroner. 'Eddie' was a care-experienced 18-year-old, who tragically died in 2019 from diabetic ketoacidosis.

Warrington SAB - Safeguarding Adult Review (Executive Summary) - Laura, November 2020

Gloucestershire Safeguarding Adults Board extends our full sympathies to Laura’s family. Whilst this Safeguarding Adult Review was undertaken by Warrington SAB, we accept the findings of their report and wish to provide further assurance that our partnership is committed to learning from her tragic death.  

7-minute briefings

These concise 7‑minute Safeguarding Adults Review briefings have been created to share key learning from vital reviews and help staff embed that learning into practice.

 

Resources

SAR Referral Form - use this form to refer a case for review. 

Information Gathering Meetings Guidance - provides steps for planning and conducting meetings to collect information effectively and consistently.

Second national analysis of Safeguarding Adults Reviews (2019-2023) - identifies priorities for improving safeguarding practice by learning from SARs. This builds on the first national analysis completed between 2017 and 2019 and published in 2020.