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Briefing for elected members - Analysis of Safeguarding Adults Reviews

This briefing summarises the key findings from the landmark study ‘Analysis of Safeguarding Adult Reviews (SARs) April 2017 – March 2019 Report’. It aims to support elected members in meeting their safeguarding responsibilities by ensuring there is correct oversight of Safeguarding Adults Reviews by Safeguarding Adults Boards, that learning from Safeguarding Adults Reviews is cascaded, that practice is improved, and that change is effected.


Elected members have a range of roles regarding safeguarding adults: as a lead member responsible for adult social care, in a scrutiny role and in responding to local casework. All elected councillors will take seriously the mantra that ‘safeguarding is everyone’s business’. 


What is a Safeguarding Adult Review?

The Care Act 2014, s44(1) (2) and (3), requires that a Safeguarding Adult Review 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. The Safeguarding Adults Board may also (section 44(4)) undertake a Safeguarding Adults Review in other cases concerning adults with care and support needs. The purpose of all reviews is to identify learning that can drive change that will prevent harm occurring in future similar circumstances.

The study analysed the findings of 231 Safeguarding Adults Reviews completed over the two-year period, drawing out common learning themes. The analysis showed self-neglect to be the most prevalent type of abuse (featuring in 45 per cent of reviews), followed by neglect/omission (37 per cent), physical abuse (19 per cent) and organisational abuse (14 per cent). This differs from the pattern of safeguarding enquiry activity, in which neglect/omission features most frequently, followed by physical abuse, financial/material abuse and psychological abuse.

Key messages regarding safeguarding adults reviews

Learning and applying lessons

When a Safeguarding Adults Review has taken place in their locality, elected members can expect to see the learning being disseminated by the Safeguarding Adults Board and by their own employer. Safeguarding Adults Review reports and associated documents, such as executive summaries and practitioner briefings provide significant learning and make an important contribution to practice development initiatives and to continuing professional development.

Key message: It is important that elected members have oversight regarding how Safeguarding Adults Review findings are disseminated and lessons learned, both in their own locality and elsewhere.

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 Safeguarding Adult Review processes.

However, the report identifies inconsistencies and issues regarding Safeguarding Adult Review processes, decision making and quality. It identifies a cluster of sector-led improvement priorities regarding the commissioning and conduct of Safeguarding Adult Reviews.

Key message: As a lead member or in a scrutiny role, it is good practice to check that your Safeguarding Adults Board has robust internal systems to provide high quality and consistent governance of relevant processes. It is important that your Safeguarding Adults Board and officers understand and implement the relevant legislation regarding referral and commissioning of Safeguarding Adults Reviews, for example how they are documented in the Safeguarding Adults Board’s Annual Report.

Key findings and recommendations about safeguarding adults

What were the findings about direct practice in safeguarding?

The Safeguarding Adults Reviews in the analysis focused both on good practice and on practice shortcomings. The most commonly noted good practice related to meeting individuals’ health needs and applying the principles of Making Safeguarding Personal, each noted in around 25 percent of cases. Also commended were continuity of involvement, attention to care and support needs, effective safeguarding and attention to mental capacity, each noted in around 15 percent of cases.

The most commonly noted practice shortcomings were: failure to attend to mental capacity; and poor risk assessment/risk management, both noted in 60 percent of cases. Failures of safeguarding were noted in half the cases, while poor recognition of carers and inadequate attention to care and/or support needs and to healthcare needs were present in over 40 percent of cases. An absence of professional curiosity meant that circumstances were sometimes taken at face value rather than explored in detail.

Most frequently mentioned good and poor practice themes

Most frequently mentioned good practice themes

Number of mentions

Most frequently mentioned poor practice themes

Number of mentions

Responding to health


Mental capacity




Risk assessment








Working with carers






Mental capacity


Responding to health



Key message: As a lead member or in a scrutiny role, it is good practice to check that your Safeguarding Adults Board is cascading learning from Safeguarding Adults Reviews to all partners through dissemination of briefings; it is important that you know it has had the desired impact on practice.  In your casework, you can see if safeguarding practice is good practice.

What were the findings on the wider organisational and interagency factors that impact upon direct practice?

While good interagency practice was noted in around a fifth of cases, shortcomings were widely noted, with poor case coordination and information-sharing present in almost three-quarters of cases.

The most frequently mentioned organisational features were pressures on staffing and workloads, present in over a quarter of cases. Absence of management scrutiny and failure to provide training were also noted, along with an absence of available resources, in some cases reflecting commissioning practice.

In terms of Safeguarding Adults Board governance, a few reports noted an absence of relevant guidance; examples included lack of policies on self-neglect, escalation, risk and mental capacity. 

Key message: Clearly these factors compromise the effectiveness of safeguarding, but they also have a direct influence on how practitioners in any one agency approach their work with an individual. As a lead member or in a scrutiny role, it is good practice to check that such factors are given due attention in the implementation of recommendations from Safeguarding Adults Reviews. It is important that your Safeguarding Adults Board has evidence that its partners have implemented recommendations, that changes have been embedded and have achieved the desired results.

Wider implications

The report identifies a significant gap in Safeguarding Adults Review findings that relate to the national legal, policy and financial context. Few Safeguarding Adults Reviews refer to the national context or highlight issues and concerns or make recommendations at this level.

Key message: As a lead member, you can ask - is there learning from a local Safeguarding Adults Review about national policy or legal frameworks, which should be raised at a national level? It is good practice to consider how you can support this.

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 Adults 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 Safeguarding Adults Reviews are carried out
  • a central place to store all Safeguarding Adults 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 message

As a lead member or in a scrutiny role, 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 check that the Safeguarding Adults Board is effectively assuring that practice, services and partnership working is improving as a result of learning from Safeguarding Adults Reviews. You can share your learning with other lead members in other councils and use their experiences to inform your own approach in turn. 

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