Second national analysis of Safeguarding Adult Reviews: April 2019 - March 2023

The purpose of the analysis 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.

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.

The analysis is split into three stages. All three are available to download. The executive summary and six briefings are also available to read.

Stage 1 report

Case characteristics; nature of the abuse and neglect; SAR reviewing process

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.

Download the Stage 1 report 

Stage 2 report

Analysis of learning

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

Download the Stage 2 report

Stage 3 report

Conclusions and improvement priorities

The final stage of the analysis draws together conclusions from the analysis overall and identifies priorities for sector-led improvement.

Download the Stage 3 report

Executive summary 

This executive summary identifies the headline findings, drawing on the detail contained in three main reports. It also includes six briefings aimed at different key stakeholders, including individuals and families, practitioners, elected members, SAB chairs and managers, senior leaders and SAB chairs and SARs authors.

Read the executive summary