Toggle Contrast

Safeguarding Adult Reviews (SARs)

The Care Act 2014 (Section 44) places a statutory duty on Safeguarding Adults Boards to carry out Safeguarding Adults Reviews (SARs).

What is a Safeguarding Adults Review?

The overall purpose of a Safeguarding Adults 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

Safeguarding Adults Reviews provide an opportunity to improve inter-agency working, for onward dissemination of lessons learnt to partner agencies, the sharing of best practice and ultimately better safeguarding of adults at risk of abuse or neglect.

A Safeguarding Adults Review is a multi-agency process that considers whether or not serious harm experienced by an adult, or group of adults at risk of abuse or neglect, could have been predicted or prevented and uses that consideration to develop learning that enables the safeguarding adults partnership in Brighton & Hove to improve its services and prevent abuse and neglect in the future.
The criteria for a Safeguarding Adults Review are:

  • an adult has died, and the SAB knows or suspects that the death resulted
    from abuse or neglect (whether or not it knew about or suspected the
    abuse or neglect before the adult died); or
  • an adult has experienced serious abuse or neglect which has resulted in
    permanent harm, reduced capacity, or quality of life (whether or not it
    knew because of physical or psychological effects), or the individual
    would have been likely to have died but for an intervention; and
  • there is concern that partner agencies could have worked more effectively
    to protect the adult.

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.

Anyone can make a referral for consideration of a Safeguarding Adults Review. Professionals are urged first to discuss your concerns with your agency’s Safeguarding Lead.

The Sussex SAR Protocol provides pan-Sussex guidance around the process and practice for undertaking Safeguarding Adults Reviews, including when and how to make a referral to Safeguarding Adults Boards.

SAR Protocol

If you would like to refer a case for consideration for a Safeguarding Adults Review, please download a referral form

Sussex SAR Referral Form

If you would like to talk about making a referral please contact the SAB Business Manager at

Alternatives to Safeguarding Adults Reviews 

The local Safeguarding Children Partnership will carry out Serious Case Reviews, or Learning Reviews, when a child under 18 dies or is seriously harmed. You can find out more about these here.

The Brighton & Hove Community Safety Partnership will conduct a Domestic Homicide Review in cases where a death is due to, or suspected to have been caused by, domestic violence. You can find out more about these here.

Taking Part in a SAR or Learning Review

To support staff asked to contribute to a review, we have written the following guidance: SARs Guidance for Staff

We also endeavor to involve those close to the adult whenever possible in these reviews, to understand their perspective on the services provided to them. We have written the following guidance to answer questions family and friends may have: SARs FAQs.

Brighton & Hove Safeguarding Adult Reviews

This Safeguarding Adults Review relates to the death of a man referred to as Craig. Craig was a 41 year-old white, British man who lived alone and had a history of mental and physical health issues. During 2019 his mental health began to deteriorate and he began receiving an increased level of support.

Several safeguarding concerns were raised in relation to Craig and he also had several hospital admissions. However, no safeguarding enquiries were undertaken. Craig was impacted by the pandemic as well as previous injuries and this all contributed to him being unable to leave his property. Contact with professionals reduced and his body was subsequently found at his flat.

The Brighton and Hove Safeguarding Adults Board commissioned a review that explored themes including safeguarding pathways and processes, multi-agency working and risk management, mental health and mental capacity, as well as the impact of resources and environment.

The Independent Reviewer has made seven recommendations that include reviews of existing statutory processes between statutory partner agencies, consideration of a multi-agency risk management framework, a review of the ADHD and neurodevelopmental strategy, a review of relevant training, as well as assurance that recommendations from other processes have been actioned.

The Safeguarding Adults Review Subgroup is currently working with partner agencies to develop an action plan to take forward these recommendations.

The full report can be accessed here .

There is also a learning briefing that can be accessed here.

SAR Craig Learning Briefing


This Safeguarding Adults Review relates to the death of a young person referred to as Charlie. Charlie had suicidal thoughts in adolescence and significantly self-harmed on many occasions. Charlie went missing regularly and was temporarily excluded from school. He identified as male in 2019.

Charlie was the subject of two periods in Hospital under the Mental Health Act due to his repeated self-harm and following the second period in hospital, He was discharged to temporary accommodation in Brighton and Hove. Charlie continued to self-harm and drink significant amounts of alcohol. A short while after he moved into temporary accommodation it is believed that Charlie took his own life.

The East Sussex and the Brighton and Hove Safeguarding Adults Boards worked together in commissioning this review as valuable shared learning opportunities were identified in relation to areas such as transitions, risk management, and cross-border working arrangements.

The Independent Reviewer grouped their findings into seven themes and made sixteen recommendations. Whilst the majority of these recommendations are directed at East Sussex and pan-Sussex organisations the Brighton and Hove SAB will continue to work with the East Sussex SAB and our partner agencies to support learning being taken forward effectively.

An Executive Summary has been produced and this can be found on the East Sussex SAB website

Executive Summary – East Sussex SAB

There is also a learning briefing that can be accessed here.

SAR Charlie Learning Briefing

This discretionary Safeguarding Adults Review, in the form of a Thematic Learning Review, concerns the deaths of two women in who died in which there were similar themes. It also incorporates learning from another Safeguarding Adults Review that was recently published by a neighbouring SAB in which these themes were identified.

Mairead, Amy, and Miss C were all young women who had care and support needs and who died from drugs overdoses, where abuse and neglect was considered to be a significant factor in their deaths with valuable learning opportunities identified. The issues that Mairead, Amy, and Miss C all experienced included domestic abuse (in particular coercion and control), mental health issues, substance misuse, having had children removed from their care, and unstable housing situations with periods of homelessness.

This comprehensive and wide-ranging review identifies a number of areas where a review of, or changes to, the current approach or thinking, may provide better outcomes and improve safeguarding for some of the most vulnerable women who find themselves in the Brighton and Hove, and wider Sussex, area. The Independent Reviewers commented that they found an uplifting desire to make a difference amongst the staff, coupled with compassion, a recognition of the ‘real world’ pressures upon all agencies together with inventive thoughts for improvements that would help women who find themselves with similar life challenges to those faced by these three victims.

The review makes ten recommendations, with partners needing to work together and to link in to existing workstreams to develop an agreed definition and accompanying terminology across Sussex for multiple and compound needs and as well as bench-marked trauma-informed approaches to improve standardisation and consistency. Commissioners are asked to explore areas that include meeting the mental health needs of people with dual diagnosis, continuing to develop refuge provision, as well as supported accommodation for those with multiple and compound needs. Partner agencies are also requested to develop a multi-agency risk management framework as well as to review their internal domestic abuse training to ensure these contain sections on coercive and controlling behaviour.

The Safeguarding Adults Review Subgroup is currently working with partner agencies to develop a multi-agency action plan to take forward these recommendations.

The full report can be accessed here: Thematic Learning Review 

There is also a learning briefing that can be accessed here: Thematic Learning Review briefing 

This Safeguarding Adults Review concerns the death of a gentleman referred to as Andrew. Andrew was a 51-year-old gentleman who had a severe learning disability, in addition to a range of longstanding health difficulties that included existing concerns around nutritional intake and weight loss. He had been living in a local authority residential care home setting for over twenty years but was admitted to hospital after sustaining significant injuries following an assault by another resident. Andrew experienced further illness whilst in hospital and his weight loss continued. On discharge he returned to the Residential Care Home but was readmitted to hospital only ten days later and passed away shortly after this.

The Brighton and Hove Safeguarding Adults Board commissioned a discretionary Safeguarding Adults Review (SAR), in the form of a ‘Desk-top Review’ to understand the circumstances leading up to the death of Andrew and to bring together the various investigative and enquiry processes undertaken by individual organisations involved to identify and share multi-agency learning in seeking to prevent a similar situation occurring again in the future.

The Independent Reviewer grouped their findings into seven themes and made six recommendations. The Brighton and Hove Safeguarding Adults Board have produced an Executive Summary based on the review report to ensure learning from the review is effectively identified and shared.

This Executive Summary includes the key findings in each of the seven themes as well as the six recommendations that were made and can be accessed here: Andrew SAR Executive SummaryThere is also a learning briefing which can be accessed here: Andrew SAR Learning Briefing

This Safeguarding Adults Review relates to the death of a young man referred to as James. James was a 42-year old man who suffered an acquired brain injury in 2010, which led to him developing significant care and support needs and subsequently receiving assistance from a range of statutory and non-statutory agencies when he returned to independent living. The issues that James experienced included substance use, self-neglect, financial abuse, exploitation and ability to make capacitated decisions following his acquired brain injury. James passed away in July 2019 from a cardiac arrest linked to drug use.

This SAR was commissioned by the BHSAB to consider whether there was sufficient understanding and awareness of James’ acquired brain injury and the impact of this, as well as the policies and procedures currently in place to support individuals with acquired brain injuries. The reviewer was also tasked with exploring whether wider existing policies and procedures were appropriately followed and whether any specialist support was sought in responding to James’ needs, as well as how learning could be effectively taken from what occurred.

The review notes that James was difficult to engage and would often not co-operate with services, and that agencies broadly acted in accordance with their internal and multi-agency policies. However, it also identifies that in the main there was little evidence of a jointly agreed care plan or multi-agency working being co-ordinated and managed by a lead professional.

It states that there wasn’t any consideration of wider professional guidance or specialist resource being sought, despite many of James’ problems stemming from his acquired brain injury, and that, ‘the absence of formal capacity assessments meant there was insufficient understanding of how ABI (acquired brain injury) was affecting James’ substance misuse and vice versa and the implications of this for his capacity to care for himself effectively.’

The full report can be accessed here:  James SAR Final Report. There is also a learning briefing which can be accessed here: James SAR Learning Briefing

This Safeguarding Adults Review (SAR) concerns the death of ‘Christopher’, a 39-year old man with a history of anxiety, learning disability and substance use. At the time of his death he was living in temporary accommodation and was receiving support from a number of local services.

Christopher died in March 2017, A referral was subsequently made to the BHSAB in 2018 and it was agreed to commission a SAR. This decision was made as it was considered that the statutory criteria that had been met; namely that an adult had died as a result of abuse or neglect, whether known or suspected, and there was concern that partner agencies could have worked together more effectively to protect the adult.

The report makes note of a lack of safeguarding interventions in the two years prior to Christopher’s death, despite evidence of self-neglect and questions about Christopher’s capacity to care for himself and make safe decisions. The report concludes that significant support was provided by a range of agencies during this period, and lack of resources was not obviously the reason for non-intervention by professionals. Rather assumptions made about his capacity to make safe decisions and a reluctance to intervene or to challenge Christopher’s view of the world.

This SAR has examined practice from some time ago, and it is reported that there have been significant improvements in terms of training and changes in service delivery. The challenge is to be confident that this input has resulted in changes in practice and better outcomes for service users.

The full report can be accessed here: Christopher SAR Final Report. There is also a learning briefing which can be accessed here: Christopher SAR Learning Briefing

This review was commissioned following the death in December 2014 of ‘X’, a homeless individual in Brighton & Hove. At the time of their death X was in contact with and / or known to a number of local services in Brighton & Hove. This review has looked to establish whether there are lessons that need to be learnt in order to better support people in the city experiencing homelessness. The review notes X’s mental health problems, learning difficulty and history of violent offending, and acknowledges that X was a very difficult and potentially dangerous person for support staff to engage with. It concludes that a range of services were in place to address X’s needs, and that they had the potential to join together in a coordinated and purposeful way.

The full report can be read here: Safeguarding Adult Review – Final Publication April 2017

A short briefing about this review can be read here – Briefing X SAR FINAL 2017

There is a range of safeguarding training available on the Learning Gateway. After reading the Briefing you may want to consider the following courses:

Or you may want to attend: Safeguarding Adults – Basic Awareness or Mental Capacity Act Briefing