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Safeguarding Adult Reviews (SARs)

The Care Act 2014 (Section 44) requires SABs to carry out Safeguarding Adults Reviews (SARs) when there is reasonable cause for concern about how partner organisations worked together to safeguard the adult and a) the adult died, and the SAB knows or suspects that the death resulted from abuse or neglect, or if b) the adult is still alive and the SAB knows or suspects that the adult has experienced serious abuse or neglect.

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 Adult Review are:

  • an adult 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.
  • an adult has not died, but the professional knows or suspects that the adult has experienced serious abuse or neglect 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.

Any professional can make a referral for consideration of a Safeguarding Adult Review. You are urged first to discuss your concerns with your agency’s Safeguarding Lead

If you would like to refer a case for consideration for a Safeguarding Adult Review, please complete a referral form.

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

Alternatives to Safeguarding Adult Reviews 

There may be alternative responses where a death has not occurred or where the SAB membership agrees that a situation does not meet the criteria but agencies will benefit from a review of actions. These include:

  • Single Agency Review: Organisations should use their own serious incident procedures if this is deemed suitable and special consideration should be given to the involvement of relevant partner organisations.
  • Multi-Agency Learning Review: A SAB commissioned review, with the same principals but less intensive than a SAR. These can be conducted in the same way as SARs.
  • Reflective Practice Session: The original participants in the case may review identified aspects of the case as part a reflective practice session chaired by the Head of Adult Safeguarding or other such suitable person, including an independent facilitator.

The findings and lessons to be learnt from such process will be presented to the SAB Sub Group, action points monitored by Case Review Sub Group, presented to the SAB and recorded in the Board’s Annual Report, as per arrangements for SARs

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.

Safeguarding Adult Reviews (SAR) Protocol

The Sussex SAR Protocol will assist professionals in deciding when to refer a case for consideration as a Safeguarding Adult Review, as well as providing guidance on the Safeguarding Adult Review process itself.

Any professional can make a referral. You can download a word version of the SAR Referral Form which is included in the protocol as an appendix.

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 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.

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.

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