Safeguarding Adults Reviews (SARs)

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Safeguarding Adult Reviews (SARs) provide a process for all partner agencies to identify the lessons that can be learned from particularly complex or serious safeguarding adults cases, where an adult in vulnerable circumstances has died or been seriously injured and abuse or neglect has been suspected.

The SAR process provides an opportunity for extended learning beyond single organisations, to allow changes/improvements to be made in policy, practice and procedures, where identified.

The SAR protocol and guidance has been developed to help provide clarity and definition of the roles, responsibilities and processes for undertaking a SAR; and improve awareness, understanding and confidence in the use of the review process, as a means of extended learning.

Click here to download a copy of Warwickshire Safeguarding’s SAR Protocol and Guidance

+ - What is the criteria for a Safeguarding Adults Review Click to collapse

s44 of the Care Act 2014 states that:

A Safeguarding Adults Board must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—
(a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and
(b) condition 1 or 2 is met.

Condition 1 is met if—
(a) the adult has died, and
(b) 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).

Condition 2 is met if—
(a) the adult is still alive, and
(b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.

A Safeguarding Adults Board may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

+ - Who can make a SAR referral Click to collapse

Any agency or professional body, elected members, MPs, the Coroner or the individual concerned, or a family member may refer cases to Warwickshire Safeguarding for consideration of a SAR. Referrals must be made in writing using the SAR referral form.

Upon receipt of a SAR referral the Chair of the Safeguarding Reviews Subgroup will determine whether or not additional scoping information is to be requested from partner agencies, this takes the form of a Rapid Review.

+ - What is a Rapid Review Click to collapse

Warwickshire Safeguarding has adopted the Rapid Review process introduced within Working Together to Safeguard Children (2018) for all new SAR Referrals which are to be progressed for further scoping and information gathering from partner agencies.

The purpose of a rapid review is to:
• gather the facts about the case, as far as they can be readily established at the time
• discuss whether there is any immediate action needed to ensure the adults safety and share any learning appropriately
• consider the potential for identifying improvements to safeguard and promote the welfare of adults with care and support needs
• decide what steps they should take next.

All agencies who have been involved with the subject adult or will be required to contribute to the rapid review. An initial scoping of agencies’ intervention will be completed, and other relevant information will need to be rapidly gathered.
To support this, agencies are asked to produce an Individual Agency Summary.

The purpose of the initial scoping and information sharing is to gather the basic facts about the case, including determining the extent of agency involvement with the adult.

More detailed information will be sought if the rapid review concludes the case has the potential to identify national or local learning and a decision is made to recommend a Safeguarding Adult Review.

+ - Who has responsibility for Safeguarding Adults Reviews (SARs) Click to collapse

The safeguarding partners are responsible for commissioning and supervising reviewers for local reviews.

The safeguarding partners should agree with the reviewer the method by which the review should be conducted. The methodology should provide a way of looking at and analysing frontline practice as well as organisational structures and learning. The methodology should be able to reach recommendations that will improve outcomes for adults.

Safeguarding partners should seek to ensure that:
• Practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
• Families, Carers including surviving adults, are invited to contribute to reviews.

+ - How is learning from Safeguarding Adults Reviews shared Click to collapse

The responsibility for learning lessons from Safeguarding Adult Reviews lies with safeguarding partners at a local level (local authorities, chief officers of police and clinical commissioning groups).

Within Warwickshire, the Safeguarding Reviews Subgroup leads this work and produces Lessons Learned Briefings and 7 Minute Briefings, which sit alongside the published report. These briefings provide a summary overview of the story of the adult, what we learned and advice for practitioners and the community to support wider learning across the County.

+ - What are the Expectations for the final SAR report Click to collapse

Safeguarding partners must ensure that the final report includes:
• A summary of any recommended improvements to be made by persons in the area to safeguarding and promote the welfare of adults;
• An analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report.
Safeguarding partners must publish the report to support wider learning, unless there are compelling circumstances, where it may not be considered appropriate to do so.

How do I access copies of Warwickshire Safeguarding Adult Reviews
Provided below are links to the Safeguarding Adult Reviews, Alternative Learning Reviews and their linked Briefings published by Warwickshire Safeguarding:

+ - 'Self-Neglect' - Published January 2024 Click to collapse

A Thematic Learning Review has been undertaken in relation to Self- Neglect.

Please see below for the full report and its findings:

Self-Neglect Thematic Learning Review – Report

7-Minute Briefing – Adult Self-Neglect

7-Minute Briefing – The Mental Capacity Act, a Basic Overview

Webpage – Warwickshire VARM (Released soon)

Training – WS Multi-Agency Training Programme

+ - 'Self-Immolation' - Published January 2024 Click to collapse

A Learning Review has been undertaken in relation to self-immolation.

Please see below for the full report and its findings:

Self-Immolation Learning Review - Report