Analysis of Safeguarding Adult Reviews: April 2019 - March 2023 (executive summary)

This second national analysis of Safeguarding Adult Reviews (SARs) in England was funded by Partners in Care and Health, supported by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS). Its purpose was to identify priorities for sector-led improvement as a result of learning from SARs completed between 2019 and 2023, a period of time that included the Covid-19 pandemic. This executive summary identifies the headline findings, drawing on the detail contained in three main reports:

Report 1: Stage one of the analysis considers the quantitative data from 652 review reports, reporting on the characteristics of the individuals involved, the types of abuse and neglect they experienced, and the nature of the SAR reviewing process.

Report 2: Stage two of the analysis focuses on the in-depth, detailed learning identified in a stratified sample of 229 SAR reports.

Report 3: Stage three of the analysis draws together conclusions from the analysis overall and identifies priorities for sector-led improvement.

The analysis builds on the findings of the first national analysis, published in 2020, which considered learning from SARs completed between 2017 and 2019. Taken together, the analyses provide a significant knowledge base about adult safeguarding in England across all types of abuse and neglect. They highlight both the shifts that have taken place and the challenges that endure.

A list of SARs completed during the four-year period by each Safeguarding Adults Board (SAB) in England was compiled from the national library of SARs and SAB websites. All 136 SABs verified and/or amended their list, submitting further, unpublished reviews also. In total 652 SARs (The overall total of SARs conducted was 675; 23 reports were withheld by SABs for reasons of sensitivity in the material (the overall total of SARs conducted was 675; 23 reports were withheld by SABs for reasons of sensitivity in the material) featuring the circumstances of 861 individuals, were included in the analysis. At stage 1 of the analysis, a data collection tool (the data collection tool was managed using Smart Survey) was used to gather structured data from the SARs. At stage 2, the learning emerging from a stratified sub-sample of 229 SARs was subject to qualitative thematic analysis.

The 652 reviews in the sample investigated a range of types of abuse and neglect, sometimes including multiple types per case (the total is therefore higher than the number of SARs), the most common being self-neglect, featured in 60% of cases (a marked rise in comparison with its 45% in the first national analysis). SARs focusing on domestic abuse have increased from 10% to 16%, with smaller increases in reviews featuring discriminatory abuse (from 1% to 2%), sexual exploitation (from 2% to 4%) and sexual abuse (from 5% to 6%). There has been no change in the prevalence of cases featuring financial abuse, but quite marked falls in SARs on physical abuse (from 19% to 14%), psychological abuse (from 8% to 4%) and organisational abuse (14% to 4%), although the distinction between organisational abuse and neglect/acts of omission can be difficult to draw. SAR reports did not always name the forms of abuse and neglect present in the circumstances under review and there were also missed opportunities to recognise and highlight certain types of abuse/neglect. Unconscious bias and stereotypical assumptions are examples of discriminatory abuse; domestic abuse might also involve physical and sexual abuse; neglect or acts of omission may not be recognised in cases of self-neglect. In care settings, neglect or acts of omission might be systemic across a service rather than isolated occurrences and thus evidence of organisational abuse.

Types of abuse and neglect

(Percentages in the above table have been rounded off to the nearest whole number.)

Modern slavery, sexual abuse, and sexual exploitation occurred more often in younger individuals whereas neglect and abuse by omission occurred more in those who were older, with self-neglect peaking in the mid years.

Psychological / emotional abuse, domestic abuse and organisational abuse were more prevalent for females, whereas financial abuse and self-neglect were slightly more prevalent for males.

Some types of abuse and neglect were likely to co-occur with others: physical abuse alongside both psychological/emotional abuse and domestic abuse; sexual abuse alongside sexual exploitation; financial abuse alongside criminal exploitation. Conversely, self-neglect and neglect/omission were more likely to stand alone.

The specification for this second national analysis identified areas of specific interest on which information was sought. These related to (i) safe care at home, (ii) organisational abuse and closed environments and (iii) ‘edge of care’ themes (discriminatory abuse, transitional safeguarding, homelessness, adult exploitation, substance dependency, modern slavery, forced marriage, county lines, radicalisation and detention centres).

Of these, the most commonly featured in the SARs was substance dependency (in 33% of SARs, in comparison with 25% in the first analysis). Abuse/neglect at home by paid/unpaid/volunteer carers featured in 23% (no direct comparison available from the first analysis) and homelessness in 13% (11% in the first analysis). Transitional safeguarding increased to 7% (from 3%). The first analysis found negligible focus on powers of entry but here 5% recorded the use of existing powers of entry, concerns about their use and/or a need for a specific adult safeguarding power of entry.

The circumstances of 861 people were reviewed in the SARs, 82% of whom were deceased. There were slightly more men (49%) than women (44%; with some regional variations in this balance) and less than 1% of reviews identified the individual as non-binary or transgender. Ages ranged across the adult life course, with 81+ being the age grouping most commonly represented. As in the first national analysis, beyond gender and age other characteristics protected in the Equality Act 2010 were only rarely reported. Ethnicity was not recorded in 67% of cases, nationality in 76%, sexual orientation in 90% and religion in 96%, raising concern that this may reflect an absence of attention to these features of people’s lives in practice.

Multiple health concerns were reported. As in the first national analysis, the most commonly reported was mental ill-health (rising from 70% of reviews to 72%) and chronic physical conditions (rising from 56% to 63%). As before, there was complex interplay between physical comorbidities and between physical and mental ill-health, sometimes related to significant life events. The most noticeable change between the two national analyses featured substance dependency, featuring in 46% of reviews (a rise from 28% previously). Impaired mobility rose from 20% to 27%, while the figure for impaired cognition fell from 30% to 23%.

The most common living situations were living alone (47%), followed by group care (20%). The most common location for the abuse/neglect was the person’s own home (73%), followed by residential/nursing care (20%). The most common perpetrator of abuse was ‘self’ (76%; in part reflecting the high proportion of self-neglect cases in the analysis), followed by care providers and other practitioners (both at 28%). Abuse by partners / relatives / friends / unpaid carers has risen from 19% in the first analysis to 25%.

This second national analysis for the first time looked at whether individuals had moved between local authority areas, thus necessitating cross-border working, and whether they were care-experienced. Cross-border moves were apparent in 12% of the SARs, almost two-thirds of which had been initiated by commissioners of services / accommodation, the remainder having been initiated by the individual themselves or by family members. In 9% of the SARs, an individual was identified as having been care-experienced as a child or young person.

Stage 2 of the analysis focused on the in-depth, detailed learning identified in a stratified sample of 229 SAR reports, noting both good practice and practice shortcomings. These are categorised across five domains: direct practice with the individual, interagency working, organisational features, SAB governance and national context. The tables below show, for each domain, the most prominent good practice themes and the most prominent practice shortcomings, along with the percentage of SARs in which each theme appeared (The main report shows the full range of different themes within each domain). Alongside the frequency counts, qualitative thematic analysis provided a narrative account of the learning, the key points of which are also reported below.

Many reviews commented positively on the personal qualities that the practitioners brought to their work. Compassion, kindness, care, non-judgementalism, empathy and sensitivity were all noted, along with commitment, dedication, professionalism, creativity, skill and diligence. The principles of making safeguarding personal were observed, along with patience and tenacity in engaging people who were reluctant or fearful. Relationship-based practice and trauma-informed approaches were both noted in some cases, along with professional curiosity, recognition of a wide range of needs and proactive risk management. On occasion, good use was made of safeguarding pathways.

Negative observations, however, outnumbered the positive by some measure. Of the 229 SARs, 99% identified practice shortcomings. So, for example, although aspects of risk assessment and management were commended in 31% of reports, it was also the most negative feature in 82%, often along with poor use of safeguarding pathways. This included cases where safeguarding need was not recognised, where referrals were made but the safeguarding triage was not appropriate, and where there were shortcomings in how section 42 enquiries were carried out and enquiries did not result in effective safeguarding plans.

It was rarely one single element of practice that had been poor; more often there had been multiple shortcomings that had combined to result in a poor outcome. This was particularly the case where checks and balances were missing elsewhere in the system, such as within the interagency, organisational or governance domains of safeguarding, adding up to system failure.

Attention to mental capacity was missing or inadequate, there was little attention to protected characteristics and legal literacy was poor. Assumptions of lifestyle choice in cases of self-neglect or multiple exclusion homelessness were problematic. Along with stereotypical assumptions, this led to a deficit-based approach and a ‘culture of resignation’ across a range of circumstances. Some practice fell short of making safeguarding personal or failed to reach an understanding of the individual’s life experience or trauma. Professional curiosity and persistence in building rapport or relationship were lacking. In some cases needs were poorly recognised; in others they were recognised but not met. There were multiple shortcomings in relation to family involvement.

There were positive observations on supervision and staff support, along with managerial oversight, access to specialist advice, training and the presence of agency procedures and guidance for practitioners. As can be seen from the frequency figures above, however, such comments were present in only a very small minority of the reports.

More common were organisational features that were seen as having had a negative impact on practice. There were multiple examples of shortcomings across several areas of organisational support. Effective safeguarding might be undermined by workloads, increasing demand, lack of management oversight through supervision, challenges of staff retention, and gaps in commissioned service provision. Shortcomings in management oversight featured prominently and were associated with delay, drift and criticisms of assessments and decision-making.

Only 28% of the 229 SARs made any reference to governance; of all the domains it was the least commented upon. Certain aspects of the management of SARs drew the most positive comment, but in very small numbers and in fact these were matched by a similar volume of negative comments on SAR governance in other reports. Overall SAR reports provide limited insight into SABs’ practice regarding the commissioning and management of reviews. Most of the negative findings in the domain of SAB governance (14%) related to policies, procedures and guidance on aspects of safeguarding practice. In some cases guidance was absent, with examples here including multiagency risk management, escalation, self-neglect, executive function, sexual exploitation and culturally competent practice. In other cases practitioners in agencies were not aware of SAB guidance that would have been relevant in the context of their work with the individual. Other guidance was noted as needing to be reviewed or strengthened.

Ninety-six (42%) of the 229 SARs made mention of the national context, although 40% of these related to the Covid-19 pandemic. Only 6 SARs noted positive features in this domain and, of these, 5 related to measures taken during the Covid-19 pandemic, such as the ‘Everyone In’ initiative. The Covid-19 pandemic also commanded the most attention in terms of negative national features, with 22% of the 229 SARs commenting here. These reviews noted its impact on adults in high-risk situations such as domestic abuse or substance misuse, on those living in supported settings, on learning disabled people and on those living with forms of neurodiversity. There was also criticism of central government’s lack of recognition of the needs of the residential sector and absence of measures to safeguard residents.

Some SARs demonstrated the impact of interconnected national features: responses to the pandemic alongside the impact of austerity and available legal powers; NHS or social care policy in the context of austerity. Others focused on gaps in national law, such as the absence of a safeguarding power of entry, or shortcomings in national policy, such as immigration policy and the limited attention given to alcohol dependence. Negative impacts from ongoing austerity were also noted.

The average number of recommendations made by the 229 SARs in the stage 2 analysis was 9, with the range extending from 0 to 36, and the most frequently occurring number being 5. Often recommendations were addressed to the SAB, with agencies frequently named as needing to take action also. Of these, the local authority appeared most frequently (51%). Action by mental health trusts (27%) and Integrated Care Boards (23%) was required in more than one fifth of the reviews, closely followed by hospital trusts (19%) and the Police (18%). Action by a wide range of national bodies was also called for.

The actions required in the recommendations fell across all domains of safeguarding, with improvements in direct practice being the most frequently sought (featured in 93% of the SARs). Here examples of priority areas included making safeguarding personal, professional curiosity, mental capacity, legal literacy and hospital discharge. In the interagency domain, recommendations commonly addressed the need for stronger communication, case coordination and multiagency risk management. Among the organisational domain priorities were improved procedures and guidance, supervision and management oversight, training and commissioning. SAB governance domain improvements focused on (i) the need for SABs to ensure that reviews could become more efficient, effective and timely and (ii) SABs’ responsibilities for seeking assurance about, and promoting the effectiveness of, multi-agency adult safeguarding practice. In national context recommendations, mental health was a prominent feature, as was the need for measures to address denied access and for improvements in drug and alcohol services. Recommendations on strengthened guidance were addressed to DHSC, and improvements to DWP’s engagement with safeguarding called for.

Beyond domain-specific actions, some SARs recognised the need for whole system change to address organisational abuse, exploitation, transitional safeguarding, homelessness, alcohol dependence, domestic abuse and safe care at home.

In addition to considering the content of the 652 SARs, the analysis looked at how SABs had commissioned and conducted the reviews.

The legal mandate contained in section 44 of the Care Act 2014 was made explicit in 77% of the SARs, but in almost half of these it was unclear whether the SAR was mandatory (meeting the criteria in section 44(1-3)) or discretionary (under section 44(4)). Eighty three percent of the SARs considered one set of circumstances, with others being thematic reviews that considered a broader number of cases. A small number of reviews were undertaken jointly with a Domestic Homicide Review or a Mental Health Homicide Review.

The most common review method used (48%) was a hybrid approach involving both documentary review and a learning event or practitioner discussion. An independent reviewer was commissioned in 75% of the reviews, and SAR panels convened in just over half. It was rare for reports to record the source of the SAR referral (missing in 75% of SARs), the length of time taken to complete the review (missing in 59%) and the period of time within the review’s scope (missing in 29%). In some cases the report did not specify whether the individual (if surviving) or their family were involved in the review.

For reviews in which the individual remained alive, few appeared to have been involved in the SAR process. In some of these cases, the individual had declined; in others they had not been invited, although reasons were not consistently given. Family members were not invited to participate in 8% of the reviews, again with reasons not always given. Where involvement of either the individual or their family had taken place, it was typically through a conversation with the reviewer, although some families also made written contributions. Advocacy was rarely used.

The most common parallel process taking place alongside, before, or after the SAR was an inquest, apparent in 35% of the SARs. Criminal investigations were present in 17%, and in 11% an NHS serious incident investigation had preceded the SAR.

Thirty three percent of SAR reports commented on issues that had arisen during the review process. Some observations were positive, for example noting good learning event attendance and candour on the part of participants. The use of virtual meetings, necessary during the pandemic, was noted to facilitate participation. More commonly the observations on process were negative, with delays caused by the Covid-19 pandemic prominent. In some cases, the SAR process had been paused completely; in others, the approach taken had been adapted to reduce demands on agencies. Parallel processes were another cause of delay, along with a lack of appropriate independent SAR reviewers. Agency involvement was sometimes noted to be poor, with failures to supply information or information of sufficient quality.

The SAR quality markers, to which evidence from the first national analysis of SARs contributed, provide detailed guidance to SABs on SAR governance. Arising from evidence from this second national analysis are aspects of governance to which SABs might pay particular attention in the commissioning and conduct of their SARs.

• Is SAB decision-making on SAR referrals timely?
• Does decision-making distinguish between mandatory and discretionary reviews?
• Are the types of abuse and neglect present clearly identified?
• Does the commissioned reviewer bring the necessary level of expertise and independence?
• Are the terms of reference (ToR) for the SAR clear?
• Do the ToR include attention to protected characteristics (Equality Act 2010)?
• Is the period of time within the review’s scope appropriate?
• Is the SAR methodology chosen appropriate?
• Are the methods for gathering information efficient and effective?
• Have all services and agencies been approached and cooperated as required?
• Are both practitioner and managerial perspectives included?
• Do parallel processes require any adaptation of the SAR approach or timing?
• Are any delays in the SAR process for appropriate reasons?
• Has the involvement of the individual and/or their family been appropriately invited?
• Has the quality of the review process and of the report been assured?
• Does the SAR report provide actionable recommendations?
• Does the SAB have a clear audit trail of decisions taken at all stages of the SAR process?
• Does the SAB’s annual report provide SAR information as required by statute?
• Does the SAR report answer the question “why?” good practice and/or practice shortcomings occurred?

The human stories that emerge through the findings of this second national analysis of SARs are stories that should move everyone involved in adult safeguarding, whether in practice, management of practice, governance and/or policy making. SARs are powerful because of the stories they tell. What this analysis also highlights, however, are the stories that are not told (Preston-Shoot, M. (2023), "Human stories about self-neglect: told, untold, untellable and unheard narratives) , and those that are not heard.

The findings of this analysis give rise to priorities for sector-led improvement, which set out a forward agenda that is a challenging one, with goals that to be achieved will require time and commitment across multiple layers of the safeguarding system. They seek to avoid simplistic solutions to repetitive findings. Yet this forward agenda also contains some early – and quite small but important – steps that will bring achievable and timely impacts through the coordination of local and national initiatives. What all the improvement priorities seek to achieve is assurance that the stories both told and untold through individual reviews are heard and contribute ultimately to effective adult safeguarding in England.

Improvement priorities

1. The National Network for SAB Chairs and the National Network of SAB Business Managers should continue to promote the SAR library. All SABs should routinely consider submitting their completed SARs to the National Network SAR library, in order to ensure their learning contributes to a lasting national repository.
2. The Department of Health and Social Care (DHSC) should work with the National Network for SAB Chairs, NHS Digital, NHS England, ADASS and the LGA to develop annual data collection that would enable tracking of the number of commissioned and completed SARs.
3. The National Network for SAB Chairs should issue guidance to SAB Chairs, Business Managers and SAR authors that SARs should seek to build on previously completed reviews.
4. DHSC should consult with the National Network for SAB Chairs, ADASS, LGA and NHS England on potential revisions to the definitions of abuse/neglect contained within the statutory guidance that accompanies the Care Act 2014.
5. The National Network for SAB Chairs should collate from SABs evidence of the outcomes of review activity and disseminate proven methods for raising awareness of SAR findings and measuring their impact.
6. The National Network for SAB Chairs should collate and disseminate case studies of how SABs have approached the management of parallel processes involving criminal investigations/prosecutions and coronial inquests.
7. Each SAB should engage with other Boards/Partnerships, and with other bodies such as ICBs and NHS England, to develop and/or review a protocol for decision-making when the criteria for more than one type of review appear to be met.
8. SABs should consider seeking assurance about local authority performance on carer assessments.
9. SABs should consider seeking assurance about levels of oversight of care at home and should ensure partnership working operationally and strategically between community safety and adult safeguarding practitioners and managers.
10.  DHSC should consider recommending legislation for an adult safeguarding power of entry along the lines of the provision available in Wales and Scotland. DHSC should also consider the inclusion of social workers in the protections afforded by the Assaults on Emergency Workers (Offences) Act 2018.
11. The National Network for SAB Chairs should escalate to DHSC concern that statutory guidance on roles and responsibilities regarding out of authority placements is insufficient, and that provision should be made in primary legislation.
12. The National Network for SAB Chairs should advise SABs to audit local practice with respect to compliance with the statutory guidance when adults for whom the local authority or ICB are responsible are placed outside their home area.
13. The National Network for SAB Chairs should continue to engage with CQC around organisational abuse and closed environments, using the findings and recommendations from SARs in this national analysis to review and strengthen current systems.
14. SABs are advised to develop and/or review policies and procedures for responding to provider concerns and especially the conduct of whole service investigations.
15. In light of repetitive findings regarding transition of young people to adult services, DHSC should consider what changes may be necessary in current legislation and guidance to provide a framework that promotes best practice in transitional safeguarding. 
16. DLUHC in partnership with DHSC, in continuing the programme of work on homelessness, should convene a whole system summit to develop a partnership approach between national government and health, housing and social care providers to develop and resource services that meet the needs of people experiencing multiple exclusion homelessness.
17. DHSC should ensure that the revision of the Mental Capacity Act Code of Practice gives sufficient guidance on assessment of executive function as part of mental capacity assessments and on approaches to capacity assessment where there has been/is evidence of prolonged and sustained substance misuse.
18. DHSC should include within the current review of mental health legislation a future legislative response to the impact, management and treatment of addiction.
19. The National Network for SAB Chairs should promote engagement by SABs with community safety and other partnerships to promote awareness of forced marriage, female genital mutilation, county lines and radicalisation as invoking adult safeguarding concerns.
20. SABs should seek assurance on the degree to which attention to protected characteristics is embedded within safeguarding practice.
21. DHSC and the Ministry of Justice should engage with the National Network for SAB Chairs on how best to strengthen the Code of Practice to promote improvement in how mental capacity is addressed in practice.
22. Consultation between DHSC and the National Network for SAB Chairs on mental health law reform should be extended to include consideration of the relationship between substance misuse (addiction and dependence) and mental illness.
23. SABs should consider the findings on direct practice and answer the question “is this happening here?”
24. The National Network for SAB Chairs and DHSC should revisit consideration of previously escalated concerns about the duty to enquire.
25. SABs should consider the findings on interagency practice and answer the question “is this happening here?”
26. Given the remit of SABs to seek assurance about the effectiveness of adult safeguarding, Boards should seek to strengthen the ways in which they review the effectiveness of policies and procedures, the outcomes of training, and the provision of supervision and management oversight.
27. DHSC should consider detailing in primary legislation duties on placing commissioners and host authorities.
28. DHSC should convene a summit involving the National Network for SAB Chairs, CQC, ADASS, NHS England and the Local Government Association to review findings from reviews on organisational abuse since 2013 and to develop a whole system programme of work that aims to transform care.
29. The National Network for SAB Chairs should sponsor a project to identify and share intelligence about methods that SABs have used to monitor and measure the impact of actions taken in response to SARs.
30. The National Network for SAB Chairs should engage with the network of SAR authors to promote the inclusion of the national context in SAR and with SCIE to emphasise the importance of the national context in the SAR quality markers.
31. The National Network for SAB Chairs should convene a summit involving organisations representing SAB strategic partners nationally and government departments with responsibilities for different types of abuse/neglect within adult safeguarding to discuss and respond to the findings and recommendations about the national context.