Safeguarding Adult Reviews (SAR)

There are two types of SAR:

1. Mandatory (there is a duty to carry out a SAR);
2. Discretionary (the duty does not apply, but carrying out a SAR would still be beneficial).

Both are statutory in nature.

Its purpose of all SAR’s is to review the practice of agencies involved with an adult (or adults) at risk, so that lessons can be learned, and practices improved.

The purpose of a SAR is not to proportion blame but to identify learning and decide how to apply this to future cases.

All SARs are subject to the six key principles that underpin all adult safeguarding work:

1. Empowerment;
2. Prevention;
3. Proportionality;
4. Protection;
5. Partnership;
6. Accountability.

For more information about these principles, see: Six Key Principles that should underpin all Adult Safeguarding Work.

The following principles should also be applied:

1. There should be a culture of continuous learning and improvement across organisations that work together to safeguard and promote the Wellbeing of adults, identifying opportunities to draw on what works and promote good practice;
2. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
3. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
4. Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed;
5. Families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

If the adult is still alive all of the overarching aims, duties, and principles of adult safeguarding apply.

See: Overarching Aims, Duties and Principles Procedure.

A mandatory SAR is a SAR that must be carried out because the duties set out in sections 44 (1), (2) and (3) of the Care Act 2014 apply:

1. There is a reasonable course for concern about how the SAB, its members or other persons involved worked together to safeguard the adult; and
2. The adult has died, and it is known or suspected that the death resulted from abuse or neglect; or
3. The adult is alive, but it is known or suspected that they have experienced serious abuse or neglect.

Note: It is irrelevant whether or not the adult is known to the local authority, or whether or not they are being provided with support or services to meet their care and support needs.

With regard to b. above, indicators that this condition is met could include:

• The adult would have been likely to have died but for an intervention;
• The adult has suffered permanent harm;
• The adult has reduced capacity or quality of life (whether because of physical or psychological side effects) as a result of the abuse or neglect.

A discretionary SAR is a SAR that is carried out when the absolute duty to do so (set out above) does not apply. Under Section 44 (4) of the Care Act SABs are free to arrange for a discretionary SAR to be carried out in any other situation involving an adult in its area with needs for care and support where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect, and can include exploring examples of good practice that can be applied to future cases.

Any agency or professional may refer a case that they consider meets the criteria for either a mandatory or discretionary SAR to be carried out as outlined above.

The SAR Referral form can be found in the relevant section of the Contacts and Practice Resources area.

All referrals should be reviewed by the Safeguarding Adults Board (SAB) to ensure that the conditions for carrying out a Safeguarding Adults Review (SAR) have been met.

The Chair of the SAB is ultimately responsible for making any final decision. However, wherever possible all members of the board should be in agreement.

The decision to accept (or not to accept) the referral should be clearly recorded in line with local recording requirements.

Once a referral is accepted the SAB should appoint an Independent Chair for the SAR Panel.

The Independent Chair must have appropriate skills and experience which should include:

1. Strong leadership and ability to motivate others;
2. Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
3. Collaborative problem-solving experience and knowledge of participative approaches;
4. Good analytic skills and ability to manage qualitative data;
5. Safeguarding knowledge.

There will also be a need to address the budgetary requirements for undertaking the SAR. This is the responsibility of the Chair of the SAB.

The referrer should be notified of the decision made.

In the event of a SAR referral being rejected, the reason/s that conditions have not been met should be clearly recorded in line with local recording requirements. In particular, if there is no duty to carry out a mandatory SAR, the reason that a discretionary SAR is not being carried out should be clear.

The referrer should be notified of the decision made.

If the referrer is dissatisfied with the decision, they can discuss their concerns with the Chair of the SAB or make a formal complaint.

The Safeguarding Adults Review (SAR) Panel should determine what process each SAR will follow.

The approach should be proportionate to the scale of the abuse or neglect that has occurred, the impact on the person and the level of complexity in the issues to be examined during the review.

The adult and/or their family or representative should be consulted when deciding how to complete the SAR, so that they can be as involved as possible.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of people who have died or been seriously abused or neglected.

The SAR should be completed within a reasonable period of time and in any event within six months of initiation, unless there are good reasons for a longer time period.

In all cases

The SAR Panel should ensure that all relevant persons are involved.

For example:

1. Professionals involved with the adult;
2. Organisations involved with the adult;
3. Family members;
4. Carer's (informal and paid).

In some cases, it may be deemed necessary to also involve the person who caused (or is suspected of causing) the abuse or neglect.

If the adult is alive

If the adult is still alive, they must also be involved in the process.

If the SAR Panel requests a person or organisation supply information to support the process they have a duty to comply with that request under s45 of the Care Act.

All information sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

If the adult is alive there is a statutory duty to ensure they receive the support they need to enable them to understand and/or participate in the SAR process.

If they are already in receipt of advocacy support under Section 67 of The Care Act, The Mental Capacity Act 2005, or the Mental Health Act it is appropriate to establish whether the existing advocate is able to provide this support.

Otherwise, the duty to appoint an advocate under Section 68 of the Care Act must be considered.

For further information about the duty to appoint an independent advocate see: The Duty to Provide an Independent Advocate.

A copy of the report should be provided to anyone who has requested it, particularly the adult (if they are alive), and their family (if involved in the SAR).

The Chair of the SAB should take steps to ensure the adult (if they are alive) and their family understands the findings of the report and the recommendations it has made.

SAR's involving CQC registered providers

If the SAR has explored the practice of a care provider regulated by the Care Quality Commission (CQC), a copy of the report should be provided to the CQC. Copies of any specific documentation or evidence submitted by the care provider as part of the SAR should also be provided to the CQC if it is requested.

All Overview Reports should be made published on the Safeguarding Adults Board website.

To view the reports for your area, use the relevant link below:

Central Bedfordshire: Safeguarding Adult Review Report. 

Bedford Borough: Safeguarding Adults Reviews. 

Luton: Safeguarding Adult Reviews. 

Any actions should be recorded in an Action Plan. It should be clear which agency/organisation is responsible for carrying out each action and timeframe for having done so.

The Chair of the SAB is responsible for reviewing the Action Plan and monitoring progress of the actions.

The following information from each Safeguarding Adults Review (SAR) must be recorded in the annual SAB Report:

1. The findings of the SAR;
2. What actions have been taken (or will be taken) in relation to those findings;
3. Where a recommendation has not been implemented, the reason/s for that decision.

Central Bedfordshire: Annual reports.

Bedford Borough: Safeguarding Adults Publications.

Luton: Safeguarding Adult Reviews.