Briefing for Safeguarding Adult Board chairs and business managers - 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 Safeguarding Adults Board (SAB) Chairs and Business Managers in meeting their statutory responsibilities. It supports them to ensure that SARs are given correct oversight, learning is cascaded, practice is improved and change is effected.


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 Adult Review (SAR)?

The Care Act 2014, sections 44(1), (2) and (3), requires that a Safeguarding Adult 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 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.

Governance of Safeguarding Adult Review (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.

Key message: The study identifies inconsistencies and concerns regarding Safeguarding Adult Review processes, decision-making and quality. The report identifies a cluster of sector-led improvement priorities regarding the commissioning and conduct of SARs. Safeguarding Adults Boards are advised to formally consider the report and identify areas for local learning and improvement.

Statutory guidance on Safeguarding Adults Review 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 recorded 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. SABs may determine the review methodology and the means by which information is collected and analysed, but practitioners should be involved. Family members, and the individual where they are still alive, should be invited to participate.

Key messages

  • It is important that Safeguarding Adults Boards ensure that all decision-making is timely, beginning with consideration of Safeguarding Adults Review (SAR) referrals.
  • 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 have been involved and this is recorded, including the offer and provision of advocacy to support their engagement.

Learning and applying lessons

Statutory guidance outlines expectations regarding the reporting and use of findings. This guidance says that Safeguarding Adults Reviews (SARs) do not have to be published but that Safeguarding Adults Boards’ (SABs) annual reports 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. This study found that not all SAB annual reports comply with the requirements in the statutory guidance. 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.

Key message: 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 SAR(s) undertaken during that year.

Quality standards for Safeguarding Adults Reviews (SARs)   

Quality Marker outlines 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 messages

  • It is important that Safeguarding Adults Boards (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 and they acquire evidence that reviews have had the desired impact on practice and service provision.    
  • The findings of this study give rise to 12 key questions that SAB Chairs and Managers might ask themselves during their management of any SAR process.

SAB governance: key questions for SABs and SAR authors

  1. Has decision-making distinguished between mandatory and statutory SAR?
  2. Has decision-making on referrals been timely?
  3. What types of abuse and/or neglect are the main and secondary concerns?
  4. What methodology has been chosen 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. 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 Safeguarding Adult Reviews 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 Board (SAB) Chair or Business Manager, it is good practice to seek assurance from partners that they are meeting their statutory responsibilities regarding safeguarding adults in the area.

It is important to provide the oversight and leadership, which 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.

The full report and an executive summary are published by the Local Government Association: