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3.19 Safeguarding Adult Reviews


  1. Criteria
  2. Purpose
  3. Learning from Safeguarding Adult Reviews
  4. Links to Safeguarding Adult Review Reports

1. Criteria

Guidance on Safeguarding Adults reviews can be found at paragraphs 14.133 -14.148 of the statutory Care and Support Statutory Guidance.

A Safeguarding Adult Review is a review of the practice of agencies involved with an Adult at Risk, commissioned to facilitate agencies to learn lessons and improve the way in which they work. Any agency or professional may refer a case.

A Safeguarding Adult Review should be considered 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 more effectively to protect the adult;
  • 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 SARs, something can be considered serious abuse or neglect where, for example the individual would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect;
  • SABs are free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

2. Purpose

The purpose of having a Safeguarding Adult Review is not to re-investigate nor to apportion blame, it is:

  • Lessons learnt - to establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard Adults at Risk;
  • Review of procedures - to review the effectiveness of procedures (both multi-agency and those of individual organisations);
  • Improve practice:
    • To inform and improve local inter-agency practice;
    • To improve practice by acting on learning (developing best practice).
  • Reports - to prepare or commission an overview report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action.

Where there are possible grounds for both a Safeguarding Adult Review and a Domestic Homicide Review, a decision should be made at the outset by the two decision makers as to which process is to lead and who is to chair with a final joint report being taken to both commissioning bodies.

The SAB should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

3. Learning from Safeguarding Adult Reviews

Colleagues in all agencies also need to be aware of the recommendations of relevant Safeguarding Adult Review Reports / Executive Summaries nationwide, and the impact upon their own practice and upon inter-agency co-operation on a day-to-day basis. The implications of national Safeguarding Adult Review reports for Safeguarding Adults in Plymouth will be discussed and disseminated to multi-agency professionals by the Safeguarding Adults Board.

4. Links to Safeguarding Adult Review Reports

Winterbourne View

The Murder of Gemma Hayter

The Murder of Steven Hoskin

Report of the Mid Staffordshire NHS Foundation Trust Inquiry