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Briefing for authors of Safeguarding Adult Reviews: 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 authors commissioned to undertake a Safeguarding Adult Review (SAR) to carry out their work in compliance with statutory guidance and to achieve learning that can inform improvement priorities in adult safeguarding.


This study builds on learning from the first national analysis of SARs completed over a two-year period, April 2017 - March 2019, which considered learning from 231 reviews. In this second analysis, all 136 Safeguarding Adults Boards (SABs) responded with details of SARs completed in the four-year period, enabling a comprehensive picture of review activity. A total of 652 reviews were included and, with some SARs featuring more than one individual, the circumstances of 861 people were considered,

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 (SAR)?

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. Under section 44(4) a SAR can be undertaken in any other case concerning an adult with care and support needs.

Adult safeguarding

All Safeguarding Adults Reviews (SARs) are statutory; the distinction to be drawn is between SARs that are mandatory and those that are discretionary. Not all Safeguarding Adults Boards and SAR authors appear to have appreciated this distinction, referring inaccurately to ‘statutory’ and ‘non-statutory’ or ‘learning’ reviews. It is important that SAR authors are clear in their report about the legal mandate for the review. Some reports, while referring to the Care Act 2014 did not identify whether the SAR was mandatory or discretionary. A few did not mention any legal mandate at all.

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 SARs.

As indicated above, some reports convey an incomplete or inaccurate understanding of the mandate in the Care Act 2014 s44. A concern highlighted in the first national analysis has emerged again in this study, namely that reports pay insufficient attention to race, gender, sexuality, disability and other protected characteristics in the Equality Act 2010. Variable practice was found in whether or not the types of abuse or neglect being considered were named, and what period of time was being covered by the review. Often missing too is recognition, in analysis of findings and in recommendations, of where the national legal, policy and financial context is hindering how services are able to respond to adult safeguarding concerns and to meeting the needs of adults at risk of abuse/neglect.

SAR authors should ensure that reports consider the impact of a person’s protected characteristics on how services identified and responded to care and support and treatment needs, and to safeguarding risks.

Statutory guidance on SAR governance and processes

The Care Act 2014 statutory guidance, which must be followed unless there are good reasons to justify departure from it, specifies requirements to which SABs and SAR authors must give recorded due regard. Ideally, reviews should be completed within six months, although parallel processes, such as criminal investigations or Coroner inquests, may lengthen the timescale. Given the period covered by this second national analysis, it is not surprising that timescales were also extended as a result of the Covid-19 pandemic. Safeguarding Adults Boards may determine the review methodology and the means by which information is collected and analysed, but practitioners should be involved. The guidance also requires that family members, and the individual where they are still alive, should be invited to participate in the review process. Not all SAR reports are clear whether/how family members have been involved, or about the reasons for any non-involvement.

Key messages:

  • It is important that SAR authors work closely with Safeguarding Adults Boards to ensure that all decision-making and review actions are conducted in a timely way. SAR reports 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 in the report.
  • It is important that reviewers comment in their SAR reports 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, 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 have been involved and this is recorded, including the offer and provision of advocacy to support their engagement.

Learning and applying lessons

The learning that emerges from the SARs included in this study is spread across five domains of safeguarding: direct work with the individual(s) concerned; interagency collaboration; organisational features within the agencies involved; Safeguarding Adult Board governance; the national legal, policy and financial context. Shortcomings in direct work are often traceable to features in the wider domains. Findings of shortcomings across direct practice, interagency collaboration and organisational features are repetitive. SAR recommendations sometimes display optimistic faith in reminding practitioners of the core components of best practice, and services of the importance of multi-agency meetings, information-sharing, review of procedures and provision of training and supervision. Reviews sometimes fail to answer the question “why is best practice is not being achieved?” Why are reviews still reporting the same findings and offering repetitive recommendations locally and nationally? Although a greater focus was found on the national legal, policy and financial context within which adult safeguarding is situated in this second analysis, there is minimal focus on this domain as part of the explanatory story.

SAR reports make variable use of research that is relevant to the type of abuse and neglect involved, and make limited reference to other SARs conducted locally, regionally or nationally. There is a tendency, therefore, towards lessons being learned anew rather than the existing evidence-base being used to identify where practice and service shortfalls need to be remedied.

It is good practice for SAR authors to situate adult safeguarding in organisational, interagency, national legal, policy and financial contexts. It is best practice to direct recommendations to national bodies where change appears indicated that is beyond the scope of an individual Safeguarding Adult Board to achieve.

It is good practice for SAR authors to make wide use of research and learning from previous SARs to provide a benchmark for evaluating practice in the circumstances subject to review.

It is appropriate for SAR authors to make recommendations on how SAs disseminate SAR findings and review the impact of SAR recommendations on practice and service enhancement.

Quality standards for Safeguarding Adult Reviews

Quality Markers1 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. Omitting to use research relevant to the type of abuse and neglect that the case involves, and making limited reference to other SARs conducted locally, regionally or nationally makes it more difficult to offer reflections on what has already been done to improve and enhance services and practice and what remains to be achieved.

Key messages: It is good practice for SAR report authors to use the Quality Markers as a benchmark for guiding their review work and to ensure that research evidence and learning from elsewhere informs their thinking. 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 there remains more to achieve to improve adult safeguarding.

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 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 (LINK) 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.


As SAR author, your role includes ensuring that the requirements and expectations of the SAR Quality Markers and the statutory guidance are adhered to. It is important that your recommendations are clear, informed by the evidence collated and analysed. It is important that the recommendations are learning oriented, to assist the Safeguarding Adults Board in seeking assurance from partners that they are meeting their statutory responsibilities for safeguarding adults and that practice, services and partnership working will improve as a result of learning from SARs.

The full second national analysis report and an executive summary are published by the Local Government Association. Other briefings are available, presenting summary information for practitioners, senior leaders, SAB chairs and business managers, elected members 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.