This chapter provides information for multi-agency practitioners about safeguarding adult reviews which must be undertaken by the Safeguarding Adults Board when certain criteria are met.


Safeguarding Adult Boards across Leicester, Leicestershire and Rutland

See also Local Guidance and Templates for additional SAR guidance


Safeguarding Adult Reviews (Leicester Safeguarding Adult Board)

Learning from Safeguarding Adult Reviews (Leicestershire and Rutland Safeguarding Adults Board)

Care and Support Statutory Guidance, Chapter 14 (Department of Health and Social Care)

1. Introduction

The Care Act 2014  introduced new duties and requirements of local authorities, and their partner agencies, in a number of areas, including safeguarding adults. It provides, for the first time, a legislative framework for those working in adult safeguarding. One of these requirements is for the local Safeguarding Adults Board to arrange a Safeguarding Adults Review (SAR) when certain criteria are met.

This chapter provides an overview of the Safeguarding Adults Board’s responsibility to arrange a SAR. It also sets out the requirement of the local authority to arrange for independent advocacy for the person subject to a SAR, where appropriate.

2. Criteria

Safeguarding Adults Boards (SABs) must arrange for a SAR to be conducted when an adult in its area dies as a result of abuse or neglect (which is either known or suspected) and there is concern that partner agencies could have worked more effectively to protect the adult.

SABs must also conduct a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect

In the context of a SAR it would be considered that there was serious abuse or neglect where, for example:

  • the person would have been likely to have died but for an intervention;
  • the person suffered permanent harm;
  • the person has reduced capacity or quality of life (whether because of physical or psychological effects).

A SAB can arrange for a SAR in any other situation involving an adult with needs for care and support.

The adult who is the subject of a SAR need not have been in receipt of care and support services for the SAB to arrange a review.

When undertaking the SAR, the SAB should be primarily concerned with deciding what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. A case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults with needs for care and support.

A SAR may also be used to explore examples of good practice where this may identify lessons that can be applied to future cases. Early discussions need to take place with the adult, their family and friends to agree how they wish to be involved.

In some instances, the adult subject to the SAR will still be alive. In such circumstances, the local authority must arrange, where necessary, for an independent advocate to support and represent an adult who is the subject of a SAR (see Independent Advocacy chapter).

Where an independent advocate has already been arranged under the Care Act 2014 or under the Mental Capacity Act 2005 then, unless inappropriate, the same advocate should be used.

It is critical the adult is supported in what may feel a daunting process. A person who is thought to have been abused or neglected may be demoralised, frightened, embarrassed or upset; independent advocacy provided to help them to be a central part of the review will be crucial.

3. Purpose of a Safeguarding Adult Review

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 to the adult in question. This is so lessons can be learned from the case and applied to future practice in order to prevent similar harm occurring again.

The purpose of a SAR is 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, Social Work England, the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.

If individuals and organisations are to be able to learn lessons from what occurred, it is vital that the SAR process is trusted and is a safe experience for participants that encourages honesty, transparency and sharing of information in order to achieve maximum benefit. If individuals and organisations are fearful of the SAR process, their response will be defensive and their participation guarded and partial.

4. Incorporating Safeguarding Principles

The SAR should reflect the six safeguarding principles (see Safeguarding: What it is and Why does it Matter?). The SAB should agree terms of reference for any SAR they arrange. These should be published and openly available.

The following principles should be applied by SABs and their partner organisations to all SARs:

  • learning and improvement – there should be a culture of continuous learning and improvement across the organisations, identifying opportunities to draw on what works and promote good practice;
  • proportionality – the approach taken should be proportionate according to the scale and level of complexity of the issues being examined;
  • independent – they should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
  • involvement of professionals – professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
  • involvement of families – families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

5. Safeguarding Adults Review Process

The process for undertaking a SAR should be determined locally according to the specific situation and individual circumstances. No one model is applicable for all cases.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of adults who have died or been seriously abused or neglected.

It is essential that the recommendations and action plans from a SAR are followed through by the SAB, and their progress closely monitored.

The SAB should ensure that professionals and organisations who were involved with the adult are included in the review process. The SAR should also communicate with the adult, and /or, their family. In some cases it may be appropriate to try to speak with the person who caused the abuse or neglect.

It is expected that those undertaking a SAR will have appropriate skills and experience which should include:

  • strong leadership and ability to motivate others;
  • expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
  • collaborative problem solving experience and knowledge of participative approaches;
  • good analytic skills and ability to manage qualitative data;
  • safeguarding knowledge;
  • inclined to promote an open, reflective learning culture.

The SAB should aim for completion of a SAR within a reasonable period of time. This should usually be within six months of initiating it, unless there are good reasons for a longer period being required, for example, because of potential prejudice to related court proceedings. During the SAR process, every effort should be made to capture any learning points from the case about improvements needed, and to take corrective action as appropriate.

6. Links with other Reviews

Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews

Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children

In setting up a SAR, the SAB should also consider how the process can dovetail with any other relevant investigations that are running parallel, such as a Child Safeguarding Practice Review or Domestic Homicide Review (DHR), a criminal investigation or an inquest.

When victims of domestic homicide are aged between 16 and 18, there are separate requirements in statutory guidance for both a Child Safeguarding Practice Reivew and a DHR. Where such reviews may be relevant to a SAR (for example, because they concern the same perpetrator), consideration should be given to how SARs, DHRs and Child Safeguarding Practice Reviews can be managed in parallel as effectively as possible, so organisations and professionals can learn from the case.

It may be helpful when running a SAR, DHR or Child Safeguarding Practice Review in parallel to establish at the outset all the relevant areas that need to be addressed, to reduce potential for duplication for families and staff. Any SAR will need to take account of a coroner‘s inquiry, and / or any criminal investigation related to the case, including disclosure issues, to ensure that relevant information can be shared without incurring significant delay in the review process. It will be the responsibility of the manager of the SAR to ensure contact is made with the Chair of any parallel process in order to minimise avoidable duplication.

7. Findings from SARs

The SAB should include the findings from any SAR it conducts in its Annual Report. It should include a summary of actions taken, or to be taken in relation to those findings. Where the SAB decides not to implement any action it must state the reason for that decision in the Annual Report.

SAR reports should:

  • provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence, if possible;
  • be written in plain English;
  • contain findings of practical value to organisations and professionals.

In the interest of transparency and disseminating learning, the SAB should consider publishing a SAR report whilst maintaining the confidentiality for those involved as appropriate.