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Safeguarding Adults Reviews (SARs)

This page contains relevant information and guidance relating to Safeguarding Adult Reviews published by Warwickshire Safeguarding and their Rapid Reviews.

Safeguarding Adults 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 further 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.

Download: WS SARs Protocol and Guidance v4.0


s44 of the Care Act 2014:

(1) An SAB 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.

(2) 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).

(3) Condition 2 is met if—

(a) the adult is still alive, and
(b) the SAB knows or suspects that the adult has experienced serious1 abuse or neglect.

(4) An SAB 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).

Rapid Review

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.

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.


The responsibility for learning lessons from serious safeguarding incidents lies locally with the Safeguarding Reviews Subgroup, safeguarding partners (local authorities, chief officers of police and clinical commissioning groups), and Warwickshire Safeguarding Business Team.

SAR Reports and Briefings

Below are links to the Safeguarding Adult Reviews, Alternative Learning Reviews and their linked Briefings published by Warwickshire Safeguarding;

A Safeguarding Adult Review has been undertaken in relation to the case of ‘Alan’ published November 2021.

Please see below the full report and a statement issued by Warwickshire Safeguarding Partnership:

'Alan' Safeguarding Adult Review - Full Report 

'Alan' - Lessons Learned Breifing

A Safeguarding Adult Review has been undertaken in relation to the case of ‘Peter’ published September 2020.

Please see below the full report and a statement issued by Warwickshire Safeguarding Partnership:

'Peter' Safeguarding Adult Review - Full Report
'Peter' Safeguarding Adult Review - WSP Statement

'Peter' - Lessons Learned Briefing 
Self-Neglect - 7-minute Briefing


Easy read resources about coroners and inquests launched for people with a learning disability and family carers

The ‘Stop People with a Learning Disability Dying Too Young group’ have published easy to read resources about coroners and inquests for people with a learning disability. These resources have been made available to help people with learning disabilities and family carers to better understand the role of coroners and purpose of an inquest:

Think Family Protocol

Protocol and Practice Guidance

Everyone has a responsibility to take a ‘Think Family’ approach in the context of safeguarding children and adults. Warwickshire Safeguarding recognise this to be a shared responsibility which must be at the heart of practice across all partner agencies within the Partnership. The Warwickshire Think Family Protocol is a commitment from Warwickshire Safeguarding which promotes a ‘Think Family’ approach by all partner agencies.

Practice Guidance

The following practice guidance is for practitioners and managers working with children or adults at risk of abuse or neglect. It supplements the Warwickshire Think Family Protocol.

The guidance will help you to:

  1. Make sure you consider for the needs of the family for each of the headings in the diagram below; and
  2. Record and share relevant information, to understand its significance and take appropriate action.

Think family practiceguidance270422v20

Click on each sub-heading below to see key questions to help you support a child, young person and/or adult within a family. Think about the impact of your answer and the risk of doing nothing.

  • Do you understand the relationships within the family especially where parents, carers and relevant ex-partners are involved with services?
  • Have you checked whether there is relevant historical evidence of previous contact with drug and alcohol/ mental health/ forensic services and police/ Youth Offending Team/ Probation services for parents/carers/partners and ex-partners?
  • Are professional boundaries flexible so children do not fall between services and are not left at risk?
  • Have you recorded relevant information in writing, e.g. when clarifying concerns by telephone between service areas?
  • When working with an adult service user, have you considered the impact of any caring responsibilities on the child or young person within the family?
  • Have you identified all the agency safeguarding leads for the children/adults within each of the organisations known to be involved in the case?
  • Have you gained the informed consent of any adults you would like to refer to another agency? Have you gained the informed consent of parents before sharing information about them and their child, or unborn child, for early help or targeted services?
    (Consent should be in writing where the information is particularly sensitive, for example, about the mental health of the adult. Verbal consent should be recorded in case notes. Adults, and children who are old enough, must understand why this information is needed and who it will be shared with).
  • Have you discussed your concerns about children or unborn children with their parents, where safe to do so, to inform them you are planning to make a referral to MASH?
    (Professionals are expected to inform parents they are making a referral to the MASH unless such discussions will place the child at increased risk of significant harm or cause further significant harm. Where the decision is made not to inform parents about a referral, the reason for this should be recorded on the child’s file).
  • Have you ensured that information disclosed without consent is relevant and only disclosed to those professionals that need to know? Have the reasons for disclosure been clearly recorded and consideration been given to the proportionality of disclosure against non-disclosure?
  • Have you referred to the WSCB procedures on ‘Information Sharing’ when dealing with a child protection case?
  • Have you liaised with professionals in Primary Care i.e. GPs and Health Visitors to seek general advice and consultation?
  • Have you sought advice from supervisors and team managers in children and adult social care?
  • Have you sought advice from experienced colleagues in your team or organisation?
  • Have you obtained advice from the Children’s Duty and Assessment team or from the allocated worker?
  • Have you consulted with the paediatrician, who is the designated doctor for child protection, if appropriate?
  • Have you contacted the relevant Consultant Psychiatrist for advice on those cases raising the greatest level of concern due to mental health/learning disabilities; and have you recorded this advice as part of the case file?
  • Have you sought advice from your domestic violence lead, in cases related to domestic violence?
  • Do you work with the family, building on the strengths of family members and providing support to meet their needs?
  • Have you asked agencies whether any of the adults within the family setting have issues that potentially put children at greater risk? e.g. a parent/carer with a history of domestic violence/other known violence; has psychosis; misuses substances – drugs or alcohol, etc.
  • Have you considered the adults in these families may themselves be adults in need of safeguarding?
  • Have you considered the needs of disabled children and their families?
    (There may be increased risks to disabled children where there is domestic violence and some disabled children may be violent toward parents/carers).
  • Have you considered the impact of any difficulties the parents/carers or pregnant women may have on their ability to meet the needs of their children or unborn child, i.e. a mental illness, a drug and alcohol problem, a learning disability or adults who are victims or perpetrators of domestic violence?
  • Have you considered the impact of the parents or carer’s illness / disability / situation on their ability to meet the development and safety needs of their children and/or unborn child?
  • Have you considered the impact of family functioning, family history, the wider family and environment factors on the parents’/carers’ capacity to respond to the children’s/unborn child’s development and safety needs?
  • Do you know which other agencies are involved and understand their role(s)?
  • Have you discussed the need for additional support or making a referral to another organisation with the parents, carer or pregnant woman’s consent?
  • Do you have any concerns about the children’s/unborn child’s well-being or safety; is action required to safeguard and promote their welfare?
  • Has a lead professional been identified to undertake an Early Help Assessment (when it is appropriate) and information shared to avoid duplication of assessments?
  • Are you working well with other practitioners ensuring that multi-disciplinary assessments, reviews and care plans are considered, shared and recorded on the individuals file?
  • Have you involved all relevant professionals from other teams, including any specialist workers, for example, psychiatrists, psychologists and family centre workers in the assessment of your case?
  • Have you considered the longer term needs and capabilities of the family when considering eligibility for services, rather than the existence or absence of incidents?
  • Is the purpose of a referral to another team clear?
  • Have you discussed the referral with your manager?
  • Have you contacted the police where there is immediate danger to the child or others including a parent/carer?
  • Have you fully and accurately documented your decisions and agreed course of actions, ensuring they are signed and dated?

There are a number of different transition processes for young people approaching adulthood i.e. transitioning into Mental Health, Social Care or into Leaving Care Services. 

  • Have you ensured a formal handover of protection plan arrangements in a timely manner so that adult services can plan provision?
  • Have you agreed who is responsible for the completion of mental capacity assessments?
  • Have you considered any ongoing safeguarding issues in the final conference where a young person has a current Child Protection Plan?
  • In relation to Young People who will be transitioning with Care & Support needs have you made a safeguarding adult referral in a timely manner where concerns exist, but a young person does not have a current Child Protection Plan?
  • Have you prepared the young person for the transition and helped them overcome any potential barriers, explained the new arrangements such as booking appointments and informed them of any new expectations under Adult Social Care?
  • Have you ensured there is an effective transfer of good quality information about the young person?
  • Have you considered planning a 3 way meeting between the young person, the present provider and the adult service provider to make introductions, share and discuss relevant information to assist the young person?
  • If an adult’s or carer’s assessment has identified that a child is involved in providing care, have you considered:
              1. The impact of the person’s needs on the young carer’s wellbeing, welfare, education and development; and
              2. Whether any of the caring responsibilities undertaken by the young carer are inappropriate?
  • Is the child’s school involved or aware of what is happening? Do they or could they offer sensitive support? Discuss this with the young carer and their family.
  • Encourage your client to explain their health condition to their child (or allow you to do it) Explain that lack of knowledge may be more damaging to the child than age appropriate information.
  • Contact Children’s Social Care for advice. Remember that some young carers and their families are reluctant to admit their role and fearful of seeking help but they would value sensitive support.
  • Have you ensured that the relevant Adult Services are aware where a young person’s behaviour raises concern of risk to others, e.g. through the transition process?



Practitioner Escalation Protocol

All practitioners working with children, young people, adults with care and support needs and carers have a responsibility towards their clients to ensure that the child’s or adult’s welfare is seen as a priority at all levels of practitioner activity. Practitioners are individually responsible for being satisfied about the substance and progress of safeguarding plans for service users.

The scope of this protocol relates to all individuals who work as practitioners with children, young people, adults with care and support needs and carers. The protocol should be used in all situations where there are concerns about practice, decision making or resource allocation and applies whether the practitioners work in a paid or voluntary capacity in the statutory and voluntary sector.

Examples of potential areas for escalation include:

A poorly framed or constructed referral by a specific agency
A failure to make a referral to Children’s/Adult’s Social Care in a timely way
Disagreement between agencies about interpretation and implementation of thresholds for intervention
Concern or disagreement about the outcome of assessments, plans, decisions and whether the appropriate case management is occurring to safeguard and promote the welfare of the child/adult
Where no or inadequate action is being taken by an agency or any other issue where a practitioner remain concerned about a child or adult
Concern there is drift or unreasonable delay in progressing a case resulting in a lack of sustained change and the outcomes have not improved
Where there are concerns about practitioner practice in any agency
Where a practitioner is uncomfortable about the position taken by their own management

Warwickshire Safeguarding have produced a Practitioner Escalation Protocol which provides clear guidance for practitioners. The protocol offers a three stage procedure and includes a reporting and monitoring processes.

All organisations should have a policy for internal escalation of disagreements about safeguarding issues which is made known to staff in their induction and refresher safeguarding training.

To access the Practitioner Escalation Protocol and supporting briefings, please click on the links below:

West Midlands Regional Adult Safeguarding Information Hub

This page has been established to host copies of all regionally agreed Policies and Procedures relating to Safeguarding Adults.

WMRASL JPEG        WM map


The policies and procedures have been developed jointly by the fourteen West Midlands Safeguarding Adults Board / Local Authority areas working together to introduce a consistent approach and practice within the adult safeguarding environment.

It is strongly advised that you check whether your Safeguarding Adults Board area has chosen to adopt these policies and procedures before making use of the documents. You should be able to clarify this through your organisational safeguarding lead.

The regional documents can be found below:

To download the full PDF file click here.

To view summary of changes to previous versions, click here.



To download the full PDF file click here.



To download the full PDF file click here.


Click here to be taken to the West Midlands Exploitation Toolkit.


Click here to be taken to the West Midlands Multi-Agency toolkit.



To download the full PDF version of the regional Safeguarding Adults Review (SAR) Policy, click here.

The West Midlands Editorial Group have produced a common content SAR Referral form, a sample leaflet for individuals, a sample leaflet for families, friends and carers, and an easy to read sample information leaflet. These resources are available here for local adoption and use by individual Adult Safeguarding Boards - check your local arrangements -


The West Midlands Adult Safeguarding Network have produced the attached framework. These resources are available here for local adoption and use by individual Adult Safeguarding Boards - check your local arrangements.

To download the full PDF file click here.



To download the full PDF file click here.


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