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Briefing for elected members: Second national analysis of Safeguarding Adult Reviews

This briefing summarises the key findings from the second national (England) study ‘Analysis of Safeguarding Adult Reviews April 2019 – March 2023’. It aims to support elected members in meeting their safeguarding responsibilities by ensuring there is correct oversight of Safeguarding Adult Reviews (SARs) carried out by Safeguarding Adults Boards (SABs), that learning from SARs is cascaded, that practice is improved, and that change is achieved. The analysis builds on the first national analysis of SARs (2020), which covered a two-year period. In this second analysis, all 136 SABs in England provided details of SARs completed in the four-year period, enabling 652 reviews to be included. Some SARs feature more than one individual; in total the circumstances of 861 people were considered.


The analysis was commissioned by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS) as Partners in Care and Health (PCH), supporting councils to improve the way they deliver adult social care and public health service.

As a lead member or in a scrutiny role, it is good practice to seek assurance from partners that they are meeting their statutory responsibilities in adult safeguarding. It is important to check that the Safeguarding Adults Board is seeking assurance on safeguarding practice and on the robustness of services, and that partnership working is improving as a result of learning from Safeguarding Adults Reviews.


Under the Care Act 2014, sections 44 (1-3), SABs must carry out a SAR when an adult with care and support needs has died or suffered serious harm, and it is suspected or known that the cause was neglect or abuse (including self-neglect), and there is concern about how agencies worked together to protect the adult from harm. The purpose is to identify learning that can drive change to prevent harm occurring in future similar circumstances. The SAB may also (section 44(4)) undertake a discretionary SAR in any other case concerning an adult with care and support needs. Thus all reviews, whether mandatory or discretionary, are statutory.

This second national analysis found that self-neglect was the type of abuse most commonly reviewed, featuring in 60 per cent of reviews (an increase from 45 per cent in the first national analysis). It was followed by neglect/omission (46 per cent), domestic abuse (16 per cent), physical abuse (14 per cent) and financial abuse (13 per cent). This differs from the pattern of safeguarding enquiry activity under section 42 of the Care Act 2014, in which neglect/omission usually features most frequently, followed by physical abuse, financial/material abuse and psychological abuse.

The learning from the analysis covers five domains of adult safeguarding: direct work with the individual(s); interagency collaboration; organisational features in the agencies involved; SAB governance; and the national legal, policy and financial context.

Conduct of Safeguarding Adult Reviews

Learning and applying lessons

When a SAR has taken place in their locality, elected members can expect to see the learning disseminated by the SAB and its partner agencies. SAR reports, executive summaries and practitioner briefings provide significant learning. They make an important contribution to practice improvement and service development, and to practitioners’ continuing professional development.

Elected members must have oversight of how Safeguarding Adults Review findings are disseminated and the lessons learned, both in their own locality and elsewhere. It is important that Safeguarding Adults Boards build on the learning from reviews completed previously, both locally and nationally. Rather than starting again each time, newly commissioned reviews should question where change recommended in previous reviews has still not been achieved.

Governance of Safeguarding Adult Review processes

Administrative law requires that decision-making should be lawful, reasonable and rational. Decision-making should be timely once individuals and agencies involved in the case have been consulted and all relevant information considered. Reasons for decisions should be recorded. Decision-making can be challenged in the High Court by way of judicial review or investigated by the Local Government and Social Care Ombudsman. This applies to SAR processes.

The national analysis identifies inconsistencies in SAR processes, decision-making and quality, and puts forward a cluster of sector-led improvement priorities for the commissioning and conduct of SARs. This includes the need for improved understanding of the mandate in the Care Act 2014 section 44, and enhanced focus on protected characteristics (Equality Act 2010). Priorities also include improving the quality of information provided to the SAR by agencies involved and ensuring that findings and recommendations build on prior learning. Also important is recognising where the national legal, policy and financial context hinders how services respond to adult safeguarding concerns and meet the needs of adults at risk of abuse/neglect.

Quality standards

Quality Markers outline national standards for the commissioning, conduct and management of SARS, and for the dissemination of learning to stimulate practice and service improvement. It remains unclear from SAR reports what impact these standards have had on the SAR process. The quality of reports is also variable. Not all refer to the review’s terms of reference. There is variable use of research relevant to the type of abuse and neglect involved, and limited reference to other SARs conducted locally, regionally or nationally. Lessons are, therefore, being constantly learned anew rather than the evidence-base being drawn upon to identify where shortfalls need to be remedied.

Elected members must seek assurance from their SAB that it has appropriate mechanisms to achieve robust governance of SAR processes, including compliance with the SAR quality markers. They should seek assurance also from the SAB that learning from SARs is cascaded, that recommendations are actioned and that required service improvements are carried out, with evidence of impact on adult safeguarding practice. They should also verify their SAB’s compliance with requirements on the inclusion of SAR details in the SAB’s annual report.

Adult safeguarding practice

What were the findings about direct practice in safeguarding?

Detailed analysis of learning was completed on 229 of the 652 SARs. There was a focus on both good practice and practice shortcomings, with the latter more prevalent. The most commonly noted good practice was in assessing and managing risk (noted in 31 per cent of cases) and in applying the principles of Making Safeguarding Personal (29 per cent). Also commended were recognition of abuse or neglect (including self-neglect), continuity of involvement, and attention to health needs (each around 22 per cent).

The most commonly noted practice shortcomings were poor risk assessment/risk management (in 82 per cent of cases), shortcomings in mental capacity assessments (58 per cent), and lack of recognition of abuse/neglect (56 per cent). Also frequently highlighted were shortcomings in making safeguarding personal (50 per cent), absence of professional curiosity (44 per cent) and attention to care and support, physical and mental health needs, each noted in around 40 per cent of cases. An absence of professional curiosity meant that circumstances were sometimes taken at face value rather than explored in detail. Other highlighted shortcomings included absence of legal literacy, superficial acceptance of individuals’ apparent reluctance to engage, poor recognition of the impact of trauma and attention to people’s living conditions.

Across findings on both good practice and practice shortcomings, there is learning about key areas if policy interest: how to promote safe care at home and in institutional settings, how to ensure access to adults at risk, and how to respond when people experience homelessness and/or substance misuse or are leaving care (transitional safeguarding).

Lead members and members in a scrutiny role must check that their Safeguarding Adults Board is cascading SAR learning on safeguarding practice to all partners through dissemination of briefings, and that evidence of its desired impact on practice is available. When carrying out casework, members can scrutinise whether safeguarding practice is good practice.

What were the findings on the wider organisational and interagency factors that impact upon direct practice?

While good interagency practice was noted in around a fifth of cases, shortcomings were widely noted, with poor case coordination and information-sharing present in almost three-quarters. Shortcomings in use of the Care Act 2014 section 42 safeguarding provision, and of multi-agency risk management meetings were each noted in around 38 per cent of cases. Also regularly featured were concerns about the quality of recording, how agencies understood their roles and responsibilities, and how services communicated across local authority and other boundaries.

The most frequently mentioned organisational features that impacted on practice were poor management oversight, poor use of policies and procedures, and pressures on staffing and workloads, present in over a quarter of cases. Failure to provide training and concerns about commissioning practice, including quality assurance of provider services and communication about ‘out of authority’ placements, were also noted, along with an absence of suitable, often specialist, resources.

In terms of Safeguarding Adults Board governance, a few reports noted an absence of relevant guidance; examples included lack of policies on self-neglect, escalation, allegations regarding people in positions of trust, risk and mental capacity.

These factors compromise the effectiveness of safeguarding, but they also have a direct influence on how practitioners in any one agency approach their work. As a lead member or in a scrutiny role, it is good practice to check that such factors are given due attention in the implementation of recommendations from Safeguarding Adults Reviews. It is important that the Safeguarding Adults Board gathers evidence on how its partners have implemented recommendations, and whether changes have been embedded and have achieved the desired results.

Wider implications

The analysis identifies a significant gap in how SARs consider the national legal, policy and financial context within which adult safeguarding takes place. While a number of SARs referred to the national context of the Covid-19 pandemic, beyond this only a minority highlighted the impact of the national context on local practice or made recommendations at this level.

Lead members and members in a scrutiny role can ask: do our local Safeguarding Adults Reviews provide learning about national policy, economic or legal frameworks that should be raised at a national level? The National Network for Safeguarding Adults Board Chairs has an agreed escalation protocol with the Department of Health and Social Care, enabling matters of national importance to be raised. It is good practice for members to consider how they can support the SAB to place a stronger focus on the impact of the national context on local safeguarding practice.

Next steps

What happens next?

This analysis supports understanding of how safeguarding can be more effective. It shows too that everyone needs to learn more about some forms of abuse and neglect - hate crime, modern slavery, sexual exploitation or self-neglect - and about abuse that happens in settings such as care homes. It also shows how SARs can be improved to ensure that clear lessons are learnt when tragedies happen.

The report sets out 31 priorities for sector-led improvements in adult safeguarding. They include:

  • Changes to law and national policy guidance
  • Strengthening pathways for escalating concerns to central government departments, for example about gaps in services and the impact on services of public sector austerity
  • Improved understanding of what effective safeguarding looks like
  • Improvements to the way Safeguarding Adult Reviews are carried out
  • Improvements to the use of the web-based library of Safeguarding Adult Reviews so that SARs can be easily found and used for learning
  • Better reporting of abuse or neglect and the reasons why it may have happened.

The full second national analysis report has been published by the Local Government Association. Other short briefings are also available, presenting summary information for practitioners, senior leaders, SAB chairs and business managers, SAR authors and individuals/families experiencing safeguarding intervention.

This work is part of ongoing work led by the Association of Directors of Adult Social Care and the Local Government Association providing resources for councils and their partners’ roles and responsibilities in keeping people safe. Find out more about safeguarding resources.