Safeguarding Adults Reviews
The Care Act 2014 introduces statutory Safeguarding Adults Reviews (previously known as Serious Case Reviews), mandates when they must be arranged and gives Safeguarding Adult Boards flexibility to choose a proportionate methodology.
A protocol has been developed in the light of the Care Act 2014 and the guidance contained within Chapter 14. This is available on the Multi Agency Policy & Procedure web page Multi Agency Safeguarding Policy and Procedures & supporting guidance
Safeguarding Adult Review's (SARs) should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied in practice to prevent similar harm occurring again.
The purpose of the reviews are not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.
It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them. If individuals and their organisations are fearful of SARs their response will be defensive and their participation guarded and partial.
Safeguarding Adults Review (SAR) Referral Form (DOCX, 33.2 KB)
Information Gathering Meetings Guidance - Safeguarding Adults Reviews (DOCX, 16.4 KB)
Out of County SARs
Warrington SAR Executive Summary 'Laura' (PDF, 690.4 KB)
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 SAR Executive Summary 'Eddie'
'Eddie' was a hugely endearing, fun and energetic care experienced 18-year-old, who tragically died in 2019 from diabetic ketoacidosis. Surrey Safeguarding Adults Board (SSAB) commissioned this Safeguarding Adults Review (SAR) due to concerns that organisational neglect contributed to his death, findings which have subsequently been made by the coroner.
Second National Analysis of Safeguarding Adult Reviews (SARs)
The purpose of the Second National Analysis of Safeguarding Adult Reviews (SARs) was to identify priorities for sector-led improvements as a result of learning from SARs completed between 2019 and 2023, a period of time that includes the COVID-19 pandemic.
The analysis builds on the findings of the first national analysis completed between 2017 and 2019 and published in 2020.
Taken together, this provides a significant knowledge base about adult safeguarding in England, across all types of abuse and neglect. They highlight both the shifts that have taken place and the challenges that endure.
The Executive Summary, Full Report and Briefings can be found at: Second National SAR Analysis