SABs must arrange a SAR when an adult in its area 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.

SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. 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. SABs are free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

The SAB should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

Early discussions need to take place with the adult, family and friends to agree how they wish to be involved. The adult who is the subject of any SAR need not have been in receipt of care and support services for the SAB to arrange a review in relation to them.

SARs should reflect the six safeguarding principles. SABs should agree Terms of Reference for any SAR they arrange and these should be published and openly available.

When undertaking SARs the records should either be anonymised through redaction or consent should be sought.

The following principles should be applied by SABs and their partner organisations to all reviews:

  • there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the wellbeing and empowerment of adults, identifying opportunities to draw on what works and promote good practice
  • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined
  • 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
  • professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; and
  • 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

Care and support statutory guidance

SARs and Learning Reviews:

In 2017 a North Somerset resident died as a result of self-inflicted injuries.  The person had many support needs and was involved with multiple agencies.  For this reason North Somerset Safeguarding Adults Board made the decision to carry out a lessons learned review.

Lessons were learned and the Board has developed the report's recommendations into an action plan:  Action plan