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Safeguarding Adults Review Reports


Below are links to key Safeguarding Adult Review reports, in order of year of publication.

Bristol Safeguarding Adults Board (2018) Safeguarding Adults Review using the Significant Incident Learning Process of the Circumstances concerning Kamil Ahmad and Mr X. Mr Ahmad was murdered by Mr X; they were both tenants in the same housing accommodation which was provided by a charity supporting people with mental health problems.

Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board (2018) Joint Serious Case Review Concerning Sexual Exploitation of Children and Adults with Needs for Care and Support in Newcastle-upon-Tyne

Enfield Safeguarding Adults Board (2018) – Safeguarding Adults Review into the care and risk management of P; an adult with learning disabilities who is believed to have committed a number of sexual assaults over a 10-year period.

West Sussex Safeguarding Adults Board (2018) Safeguarding Adult Review In respect of Matthew Bates and Gary Lewis – Mr Bates and Mr Lewis were residents of the same care home in West Sussex. Both have profound learning difficulties, cerebral palsy and are non-ambulant. They were admitted to an A&E Department on the same day, both suffering fractures to a femur.

Bristol – Safer Bristol Partnership (2017): Multi-Agency Learning Review Following The Murder of Bijan Ebrahimi, an Iranian man who was murdered after suffering years of harassment and abuse.

Plymouth Safeguarding Adults Board: Safeguarding Adults Review – Ruth Mitchell (2017) – woman with mental health problems, who died of malnutrition.

Rochdale Safeguarding Adults Board: Safeguarding Review regarding ‘Tom’ (2017) – murder of a man in his home, who had a long history of alcohol problems and was being exploited by his associates.

Bristol Safeguarding Adults Board (2017) Serious Case Review: Following the murder of a young adult, ‘Melissa’, 18 years old, in October 2014 – which identified problems with transition from children’s to adults’ services, risk assessments, and out of area placements.

Verita (2014) Independent investigation into the death of CS – a report for Southern Health NHS Foundation Trust into the death by drowning of a young man with epilepsy.

West Sussex Safeguarding Adults Board (2014) Orchard View SCR – closure of Southern Cross Healthcare care home for people with old age and dementia; the Coroner found issues of institutional abuse and neglect contributed to the deaths of five residents at their inquests.

Kent and Medway Safeguarding Vulnerable Adults Executive Board (2013) Executive Summary of a Serious Case Review: Mr J – death of a man, where concerns of exploitation and physical abuse.

Surrey Safeguarding Adults Board (2013) The Death of Mrs Gloria Foster – death of an elderly woman following withdrawal of service as result of sudden closure of home care agency.

Birmingham Safeguarding Adults Board (2012) A Serious Case Review in Respect of A2 – death of a man with complex needs.

South Gloucestershire Safeguarding Adults Board (2012) Winterbourne View – abuse by staff at hospital for adults with autism and learning disabilities.

Warwickshire Safeguarding Adults Partnership (2010) The Murder of Gemma Hayter – murder of a woman with learning disabilities.

Cornwall Adult Protection Committee (2007) The Murder of Steven Hoskins – murder of a man with learning disabilities.


Learning from SARs: A Report for the London Safeguarding Adults Board (Braye and Preston-Shoot, 2017)

A Decade of Serious Case Reviews, Hull Safeguarding Adults Partnership Board, 2014