Safeguarding Adult Reviews (SARs)

The Care Act 2014 states that Safeguarding Adult Boards (SABs) must arrange a Safeguarding Adult Review (SAR) when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked together more effectively to protect the adult. This is a statutory responsibility.

The overall purpose of a Safeguarding Adult Review is to promote learning and improve practice, not to re-investigate or to apportion blame. The objectives include establishing:

  • lessons that can be learnt from how professionals and their agencies work together
  • how effective the safeguarding procedures are
  • learning and good practice issues
  • how to improve local inter-agency practice
  • service improvement or development needs for one or more service or agency.


The SSASPB have had one SAR the full report from the SAR is below;

John (2016) (498 KB)

Lessons Learnt

Lessons learnt are shared to maximise the opportunity to better safeguard adults with care and support needs, who are or may be at risk of abuse or neglect. The Care Act 2014 requires that lessons learnt are published in the Annual Report following the conclusion of the review.

The Board has developed a SSASPB Safeguarding Adult Review protocol (626 KB) and supporting appendices which provide further information.

Lessons Learnt; key themes identified in reviews

These themes have been identified from Multi-Agency Learning Reviews and SARs.

  • Record keeping. Records need to contain as much information as possible to show reasoning behind decision-making to:
         (a) maximise the opportunity for effective supervision and also

              (b) optimise the ability of others to support the adult if the case is handed over.

  • Use of the SSASPB Escalation Guidance: Greater awareness of the Escalation Guidance is needed to encourage those working with adults to effectively resolve professional challenges at the earliest opportunity.

SSASPB lessons learnt

John (2016) (158 KB)

David (2017) (163 KB)

Emergency closure of a nursing unit (2017) (157 KB)

Other SAB lessons learnt

Anonymous 'Colin' (767 KB)

Walsall (WSAB) Adult A (518 KB)

Portsmouth - Mr. D (315 KB)