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.


SSASPB SAR publications can be found below;




A short audio clip giving an overview of the Andrew SAR and the lessons to learn from the reivew. 



  • Frank and Elsie

This SAR focuses on the response to risk presented by sexual behaviour in care/nursing settings and involves an elderly male and female neither of whom had capacity. 

SAR Frank and Elsie Final Report (331 KB)


This SAR has a theme of Self Neglect where a person was restricted to their bed in a supported housing location.  It also features Mental Capacity and to what extent this impacted on the outcome for the adult, who was a White British female in her late 60’s.



  • Clive Treacey: Discretionary SAR

Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) in respect of Clive Treacey, who died in 2017. Clive had a learning disability, epilepsy, and complex mental health needs. He was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East in 1993. This Discretionary SAR relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014.

CESAB and SSASPB appointed Professor Michael Preston-Shoot to be the author of the Discretionary SAR. All relevant organisations participated in it, contributed to the learning, and provided assurances about current adult safeguarding practices under the Care Act 2014. The Discretionary SAR makes 14 recommendations, both boards fully support the recommendations made and are committed to ensuring that the further learning identified in the review is actioned and progressed. There follows five documents - the full review report, the pen picture of Clive, the impact statement provided by Clive’s family, the Learning on a Page and the Independent Chairs’ Joint Statement.

SAR Clive (646 KB)

Clive (440 KB)

Clive's family's impact statement (104 KB)

Learning on a Page from Discretionary SAR Clive (230 KB)

Joint Safeguarding Adult Board Statement (158 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 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:
    • maximise the opportunity for effective supervision and also
    • 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.
  • Appointment of a lead professional 

The SCIE have also published a useful video regarding national recurring lessons to learn Safeguarding adults in practice Steven Hoskin ten years on.


SSASPB lessons learnt


National lessons learnt 

A national database of SARs has been compiled to assist with learning lessons from SARs which is open to professionals and the public. The data base includes SARs published from 1st April 2019. The list is searchable and will allow the use of key words including types of abuse, types of care and support need as well as place of residence and potential identified themes. A link to the website can be found here


The Care and Health Improvement Programme (CHIP) safeguarding workstream commissioned Suzy Braye, Michael Preston-Shoot and Research in Practice to undertake a review of SARs published in 2018/18 and 2018/19 to inform future priorities for sector led improvement in safeguarding adults’ practice.

The full report, Analysis of Safeguarding Adult Reviews: April 2017 - March 2019, is lengthy and academic, reflecting the considerable work that has been undertaken, the range and depth of analysis. Six shorter targeted briefings have been developed to enable easier access to the wealth of information and guidance arising from this work, links to which can be found below;