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Briefing for SAB chairs and business managers: Second National Analysis of Safeguarding Adult Reviews

This briefing summarises key findings from the second national (England) study ‘Analysis of Safeguarding Adults Reviews April 2019 – March 2023’, with particular reference to the conduct of reviews. It is particularly relevance to the work of Safeguarding Adults Board (SAB) Chairs and Business Managers in meeting their statutory responsibilities. It supports them to ensure that Safeguarding Adult Reviews (SARs) are given oversight, learning cascaded, practice improved and change achieved.


This briefing summarises key findings from the second national (England) study ‘Analysis of Safeguarding Adults Reviews April 2019 – March 2023’, with particular reference to the conduct of reviews. It is particularly relevance to the work of Safeguarding Adults Board (SAB) Chairs and Business Managers in meeting their statutory responsibilities. It supports them to ensure that Safeguarding Adult Reviews (SARs) are given oversight, learning cascaded, practice improved and change achieved. 

The second national analysis considered the findings of 652 SARs completed over the four-year period, drawing out common learning themes. Some SARs feature more than one individual and in total the circumstances of 861 people were considered. The analysis builds on learning from the first national analysis, which covered 231 SARs completed between April 2017 and March 2019. In this second study, all 136 SABs in England provided information about their SARs, enabling a complete picture of commissioned and completed review activity across the four-year period. 

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 the mandate for a Safeguarding Adult Review?

Under the Care Act 2014, sections 44 (1-3), SABs much carry out a SAR where 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. Under section 44(4) a SAR can be undertaken in any other case concerning an adult with care and support needs. The purpose of all reviews is to identify learning that can drive change to prevent harm occurring in future similar circumstances.

Eight SABs appear not to have completed any SAR within the 4-year time period. This is a timely reminder for all SABs to seek assurance that the pathway for referring cases for consideration is known and used and to address any barriers in either referral practice or decision-making on referrals.

Key messages regarding Safeguarding Adult Reviews

All Safeguarding Adults Reviews are statutory; the distinction to be drawn is between reviews that are mandatory and those that are discretionary. Not all SABs appear to have appreciated this distinction, referring inaccurately to ‘statutory’ and ‘non-statutory’ or ‘learning reviews’. Some SAR authors are not referring to any mandate in their report or, where the Care Act 2014 is referred to, are not indicating whether a commissioned review was mandatory or discretionary.

Governance of SAR 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.

However, the analysis identifies inconsistencies in SAR processes, decision-making and quality and sets out a cluster of sector-led improvement priorities regarding the commissioning and conduct of SARs. These include the need for accurate understanding of the mandate in the Care Act 2014 section 44, and for enhanced focus on protected characteristics (Equality Act 2010). Other priorities include enhancing the quality of information provided by agencies involved in reviews and ensuring that findings and recommendations build on prior learning. Also important is recognising where the national legal, policy and financial context is hindering how services are able to respond to adult safeguarding concerns and to meet the needs of adults at risk of abuse/neglect.

Safeguarding Adults Boards are advised to formally consider the report, asking the question “does that happen here?”, and to identify areas for local learning and improvement.

Statutory guidance on SAR governance and processes

Care Act 2014 statutory guidance, which must be followed unless there are good reasons to justify departure from it, specifies requirements to which SAB Chairs and Business Managers must give and record due regard. It is the SAB itself that determines whether a review is commissioned. Ideally, reviews should be completed within six months, although parallel processes, such as criminal investigations or Coroner inquests, may lengthen the timescale. It is clear that exceptional operational service demands during the Covid-19 pandemic also resulted in slower reviewing processes. SABs are free to determine the review methodology and the means by which information is collected and analysed, but practitioners should be involved, along with family members and the individual where they are still alive.

Key messages:

  • It is important that Safeguarding Adults Boards ensure that all decision-making is timely, beginning with consideration of SAR referrals. SARs should clearly outline the timeline from referral and commission to completion.
  • The agency referring the case for consideration as a SAR should be recorded.
  • It is important that the reasons for a chosen methodology and approach to reviewing the case are clearly recorded.
  • It is important that SAR reports comment on whether reasons for delay were positive, such as waiting for the conclusion of criminal proceedings, or negative, such as agencies failing to cooperate.
  • It is important that race, ethnicity and other protected characteristics are routinely addressed in reports and their significance considered.
  • Section 44(5) requires agencies to cooperate and contribute, to ensure that lessons are identified and then applied to future cases. Section 45 of the Care Act 2014 can be used to secure compliance where cooperation has not been forthcoming.
  • It is important that individuals, where still alive, and family members are involved and that this is recorded, including the offer and provision of advocacy to support their engagement. The reasons for any non-involvement should be clearly stated.

Learning and applying lessons

Statutory guidance outlines expectations on the reporting and use of findings. It indicates that SARs do not have to be published but that SABs’ annual reports should include details of SARs in progress and the findings and recommendations of completed reviews. It is important that SABs provide information about what has already been done to improve and enhance services and practice as a result of SAR findings and recommendations, and what remains to be achieved. It is important that subsequent annual reports provide updates on the outcomes that have been achieved. It is not always clear what reasons have persuaded a SAB that a SAR should not be published in full or through an executive summary.

It is important that SARs build on rather than repeat findings and recommendations from reviews that have already been completed by the commissioning SAB and also draw on learning from SARs completed elsewhere. Most SARs do not draw on available prior learning, and therefore do not evaluate what has changed and where obstacles or barriers to best practice remain. SARs are often starting again rather than building on available prior learning and its impact on practice improvement and service development. The withdrawal of published SARs from SAB websites after a set period of time, as is practice by some SABs, makes such continuity more difficult to achieve.

It is important that Safeguarding Adults Board annual reports comply with the SAR reporting requirements in the statutory guidance and include a summary of any SARs undertaken during that year.

Terms of reference or key lines of enquiry should include drawing on available learning from previously completed reviews to inform an appreciative enquiry about good practice and an analysis of where more remains to be achieved to improve adult safeguarding.

Quality standards for Safeguarding Adults Reviews (SARs)

Quality Markers outline standards for SAR reports and the surrounding processes of commissioning, management, and dissemination for practice and service improvement and enhancement. It is often not clear from SAR reports what impact the Quality Markers have had on the SAR process. The quality of reports is also variable. For example, not all reports refer back to the terms of reference that were originally set, or indeed name the types of abuse or neglect that feature in the SAR. Some reports refer to the poor quality of individual independent management reviews provided by the services involved.

Where independent authors have not been commissioned but reports written in-house, the reasoning for this approach is rarely stated. Not all reports indicate the time period that is subject to detailed analysis. There is variable use of research relevant to the type of abuse and neglect that the case involves, and limited reference to the impact on adult safeguarding of the national legal, policy and financial context.

Key messages: It is important that SABs have robust internal systems to provide high quality and consistent governance of SAR processes. It is important that SABs record how learning from SARs has been cascaded to all partners through dissemination of briefings, that they acquire evidence that recommendations have been implemented, and that learning from SARs has had the desired impact on practice and service provision.

What happens next?

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, 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 improvements in adult safeguarding. They include:

  • Changes to law and national policy guidance;
  • Strengthening the pathway 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 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 messages

As Safeguarding Adults Board Chair or Business Manager, it is good practice to seek assurance from partners that they are meeting their statutory responsibilities in adult safeguarding.

It is important to provide the oversight and leadership that are crucial to ensuring that the SAB is complying with statutory requirements and guidance on the commissioning and conduct of SARs and that it is effectively assuring improvements in practice, services and partnership working as a result of SAR learning.

Other short briefings are also available, presenting summary information for practitioners, senior leaders, SAR authors, elected members and individuals/families experience safeguarding intervention.

The full second national analysis report has been published by the Local Government Association.

  • Stage 1: Quantitative analysis - the individuals involved in the 652 SARs, the types of abuse and neglect they experienced and the nature of the SAR reports
  • Stage 2: Analysis of the detailed learning from a stratified sample of 229 reports
  • Conclusion and priorities for sector-led improvements

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.