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Briefing for individuals and their families: Second national analysis of Safeguarding Adult Reviews

This briefing summarises key findings from a second national study in England ‘Analysis of Safeguarding Adult Reviews April 2019 – March 2023’. It aims to support individuals, their relatives, advocates and friends in their involvements with adult safeguarding. The study analysed the findings of 652 Safeguarding Adult Reviews that featured the lives of 861 individuals.


This briefing summarises key findings from a second national study in England ‘Analysis of Safeguarding Adult Reviews April 2019 – March 2023’. It aims to support individuals, their relatives, advocates and friends in their involvements with adult safeguarding. The study analysed the findings of 652 Safeguarding Adult Reviews that featured the lives of 861 individuals.

The analysis and this briefing were 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.


What is a Safeguarding Adult Review?

Safeguarding Adult Boards exist in every local authority in England. They have a legal duty to help and protect adults who are at risk of abuse or neglect (including self-neglect). They so this by bringing together all the agencies and services that contribute to adult safeguarding to work on improving hoe they work together. Under the Care Act 2014 a Safeguarding Adults Board must carry out a Safeguarding Adult Review

  • 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 them.

The Board may undertake a Safeguarding Adults Review in other cases also. The purpose of all reviews is to see what can be learnt in order to prevent harm occurring in the future.

Standards for Safeguarding Adult Reviews

Guidance on the Care Act 2014 sets out requirements that Boards must follow in carrying out a Safeguarding Adults Review. These include that the individual (where they are still alive) and family members should usually be involved in the review.

There are also Quality Markers1 that set out standards for how reviews should be carried out. They include:

  • Making sure everything possible is known about a person’s circumstances;
  • Being clear about the types of abuse and/or neglect the review must concentrate on;
  • Involving the person and their family in the process;
  • Ensuring that the review process is well managed;
  • Clearly recording decisions made during the review process.

How Safeguarding Adult Reviews should be carried out

Safeguarding Adults Boards should:

  • Make sure that all decisions on Safeguarding Adults Reviews are made promptly
  • Record the reasons for how the review is done
  • In cases of delay, make sure that reports say whether the reasons were positive (e.g. waiting for criminal proceedings to finish), or negative (for example, agencies failing to cooperate)
  • Make sure that race and ethnicity, gender, disability, sexual orientation, religion, age, gender reassignment and maternity status are given more attention in reviews
  • Make sure agencies cooperate with the review so that lessons are learnt and applied in future
  • Say how individuals and family members were involved, and whether advocacy was available.

Key findings and recommendations

Self-neglect was the most common type of abuse reviewed – it featured in 60 per cent of the reviews. Other forms of abuse and neglect frequently found were neglect/omission, domestic abuse, physical abuse and financial abuse. Certain forms of abuse were more common amongst people of certain age groups; for example, sexual abuse was more common amongst young people than older people.

It is important that individuals, their relatives and friends, and their advocates know how to raise concerns about poor practice that could be abuse and neglect, for example in hospitals and in residential and nursing homes.

There are five types of learning from the analysis:

  1. How well the individual(s) and their family were safeguarded
  2. How well practitioners and services worked together
  3. In what ways the organisations providing services helped or hindered what took place
  4. How the Safeguarding Adults Board supported the organisations to work together
  5. How legal rules, policies and financial resources at national level impact on local safeguarding.

What were the findings about good and poor practice with the individual and their family?

Some reports gave examples of good practice, for example:

  • How an individual’s health, care and support needs were met
  • How the individual’s own views and wishes were recognised
  • How services provided continuity of involvement.

Many, however, noted poor practice, for example:

  • Lack of relationship-based, person-centred practice
  • Failure to assess and/or review mental capacity
  • Poor risk assessment, including failure to update risk management plans as situations evolve
  • Unwarranted assumptions about individuals making a ‘lifestyle choice’ about their situation
  • Accepting at face value an individuals’ reluctance to accept support
  • Lack of professional, concerned curiosity, for example about the impact of trauma
  • Failures to protect individuals from exploitation or coercive and controlling behaviour
  • Poor recognition of carers’ needs
  • Inadequate attention to health, mental health and care and support needs
  • Shortcomings in preparing care-experienced young people for adulthood.

Adult safeguarding practitioners should fully involve the individual who has experienced or is at risk from abuse or neglect (including self-neglect). Where safe to do so, the individual’s family and social network may have important contributions to make to reduce the risks and to provide support. It is important that individuals, their relatives and friends, and their advocates proactively raise concerns about poor practice, for example about unsafe care at home or hospital discharge arrangements.

What were the findings about what helps or hinders good practice?

Although there were some examples of good interagency practice, poor working together was more common. Agencies often did not share important information with each other and they worked in silos rather than together. Work was poorly coordinated, without any one agency knowing what everyone else was doing. More use could have been made of risk management meetings attended by all agencies involved with an individual. Sometimes services failed to refer adult safeguarding concerns to local authorities and, where they did, safeguarding enquiries were not always undertaken, or did not result in a safe situation for the individual.

In the agencies involved, there were pressures on staffing and workloads and shortages of resources. Managers sometimes were distant from decisions made. Staff sometimes had not had training, and guidance was missing. There were gaps in services, for example for people experiencing mental distress or substance misuse.

These things affect how practitioners work and make it more difficult for safeguarding to be effective. Individuals and their advocates, relatives and friends will recognise when the service being offered is inadequate or poor. When they raise concerns, these should be addressed promptly and in a person-centred way.

Learning and applying lessons

When a Safeguarding Adults Review has taken place, the Safeguarding Adults Board should make sure that the lessons learnt are shared with all the services involved and with organisations representing people who use services. Reports, briefings and summaries should be available, and learning events and discussions should take place. The Board should produce an action plan setting out how the review’s recommendations for improvement will be met. Updates on progress should be available, for example in the Board’s annual reports. Previously completed reviews should be revisited to understand how SAR learning has improved practice, and what obstacles to improvement remain.

It is important that individuals, relatives and advocates can see how lessons are being learnt from Safeguarding Adults Reviews.

Next steps

What happens next?

This research helps us to understand how safeguarding can be more effective. It also shows that everyone needs to learn more about some forms of abuse and neglect, such as hate crime, modern slavery, sexual exploitation or self-neglect. We need to recognise abuse and neglect that happens in settings such as care homes. It also shows how Safeguarding Adults Reviews can be improved to ensure that clear lessons are learnt when tragedies happen.

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

  • Changes to law and national policy guidance;
  • Escalating concerns to central government departments when national features such as law or funding impact on local practice;
  • Improved understanding of what good safeguarding looks like;
  • Improvements to the way Safeguarding Adult Reviews are carried out;
  • Improved use of the web-based library of Safeguarding Adult Reviews so that they can be easily found and used for learning;
  • Better reporting of abuse or neglect and the reasons why it may have happened.

Concluding key message

As an individual who may have experienced adult safeguarding, you will know whether or not you felt that your concerns, wishes and feelings were heard and recognised. You will know whether practitioners supported you to achieve what you wanted. Did you feel safer as a result? Did you feel that the services you were offered were excellent, satisfactory, poor or inadequate? Your feedback and contributions are important if services are to improve.

As families concerned about your relative receiving treatment, care and support at home or in a care setting, you will know whether you felt that your concerns were heard, recognised and responded to. Your feedback about how well your relatives were protected from abuse and neglect is vitally important if services are to improve further.

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 elected members.

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

See Think Local Act Personal Social Care Jargon Buster for explanation of key terms