Briefing for Safeguarding Adults Reviews authors - Analysis of Safeguarding Adults Reviews

This briefing summarises key findings from the landmark study ‘Analysis of Safeguarding Adults Reviews (SARs) April 2017 – March 2019’, with particular reference to the conduct of reviews. It is therefore of particular relevance to the work of reviewers and authors of review reports. It aims to support reviewers and authors to achieve good quality reports that can make a significant contribution to practice improvement.


This study analysed the findings of 231 Safeguarding Adults Reviews (SARs) completed over the two-year period, drawing out common learning themes.


What is the mandate for a Safeguarding Adults Review (SAR)?

The Care Act 2014, sections 44(1), (2) and (3), requires that a Safeguarding Adults Review (SAR) is undertaken 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 that agencies could have worked better to protect the adult from harm. Under section 44(4) a SAR can be undertaken in other cases concerning adults with care and support needs.

Key messages regarding safeguarding adults review

Key message: All Safeguarding Adults Reviews (SARs) are statutory; the distinction to be drawn is between reviews that are mandatory and those that are discretionary. Not all Safeguarding Adults Boards appear to have appreciated this distinction, referring inaccurately to statutory and non-statutory reviews. It is important that SAR authors are clear in their report about the legal mandate for the review.

Governance of Safeguarding Adults Reviews 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.

Key message: The study identifies inconsistencies and concerns regarding Safeguarding Adults Reviews’ (SARs) processes, decision-making and quality. The report identifies a cluster of sector-led improvement priorities to strengthen Safeguarding Adults Boards’ governance role in the commissioning and conduct of SARs.

Statutory guidance on Safeguarding Adults Reviews 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 Safeguarding Adults Review 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. Safeguarding Adults Boards may determine the review methodology and the means by which information is collected and analysed, but practitioners should be involved. This guidance requires that family members, and the individual where they are still alive, should be invited to participate in the review process.

Key messages

  • It is important that Safeguarding Adult Review (SAR) authors work closely with Safeguarding Adults Boards to ensure that all decision-making and review actions are conducted in a timely way.
  • 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 Safeguarding Adults Reviews (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. Only 25 percent of all SARs considered all five domains.

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, to lessons being learned anew rather than the existing evidence-base being used to identify where practice and service shortfalls need to be remedied.

Key messages

  • It is best practice for Safeguarding Adults Review (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 (SAB) 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 SABs disseminate SAR findings and review the impact of SAR recommendations on practice and service enhancement.

Quality standards for Safeguarding Adults Reviews  

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. There is variable use of research relevant to the type of abuse and neglect that the case involves, and limited reference to other SARs conducted locally, regionally or nationally. Lessons are, therefore, being learned anew rather than an evidence-base of best practice being developed and drawn upon to identify where practice, management and service shortfalls need to be remedied.

Key message: It is good practice for Safeguarding Adults Review report authors to use the Quality Markers as a benchmark for guiding their review work and ensure that research evidence and learning from elsewhere informs their thinking.      

The findings of this study give rise to 12 key questions that SAR reviewers and report authors might ask themselves during involvement in any SAR process.

SAB governance: key questions for SABs and SAR authors

  1. Has decision-making distinguished between mandatory and discretionary SAR?
  2. Has decision-making on referrals been timely?
  3. What types of abuse and/or neglect are the main and secondary focus?
  4. What methodology has been chose and why?
  5. What methods for gathering/exploring information have been chosen and why?
  6. What positive/negative reasons for delay have impacted on the process?
  7.  Have services and agencies cooperated as required?
  8. What approach has been taken to subject and family involvement?
  9. Do annual reports provide required information; SARs findings and actions taken in response?
  10. How has SAR quality been assured?
  11. How has the SAB captured the outcomes of action taken?
  12. Have reasons for decisions at all stages of the process been recorded?

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 a setting such as a care home. It also shows how SARs can be improved to ensure that clear lessons are learnt when tragedies happen.

The report sets out 29 priorities for improvements in adult safeguarding. They include:

  • Changes to national policy guidance;
  • Improved understanding of what effective safeguarding looks like;
  • Improvements to the way SARs are carried out;
  • A central place to store all SARs 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 Safeguarding Adults Review (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 seek 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 report and an executive summary are published by the Local Government Association: