Briefing for individuals and their families - Analysis of Safeguarding Adults Reviews

This briefing summarises key findings from the landmark study ‘Analysis of Safeguarding Adult Reviews April 2017 – March 2019’.

This briefing aims to support individuals, their relatives, advocates and friends in their involvements with adult safeguarding. The study analysed the findings of 231 Safeguarding Adult Reviews completed by 129 Safeguarding Adults Boards (SABs) over the two-year period, drawing out common learning themes.


What is a Safeguarding Adult Review?

The Care Act 2014 requires a Safeguarding Adults Board to carry out a Safeguarding Adult Review 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 that agencies could have worked better to protect the adult. The Safeguarding Adults Board may undertake a Safeguarding Adults Review in other cases also. The purpose is to see what can be learnt in order to prevent harm occurring in the future.

Standards for Safeguarding Adults Reviews

Guidance on the Care Act 2014 sets out requirements that Safeguarding Adults Boards must follow in carrying out a Safeguarding Adults Review. The requirements include that the individual (where they are still alive) and family members should usually be involved.

There are also Quality Markers that set out standards for Safeguarding Adults Review reports. They include:

  • Making sure everything possible is known about a person’s case before the report is written.
  • What types of abuse and/or neglect does the Safeguarding Adult Review concentrate on?
  • How is the Safeguarding Adult Review being carried out?
  • How has the person and their family been involved in the process?
  • How have these decisions been recorded?

Key messages

  • Safeguarding Adults Boards should ensure that all decisions are made promptly.
  • The reasons for the approach to the review should be recorded.
  • If things are delayed, Safeguarding Adults Review reports should say whether the reasons for delay were positive (e.g. waiting for criminal proceedings to finish), or negative (e.g. agencies failing to cooperate).
  • Race, ethnicity, gender, disability, religion and age should be given more attention.
  • Agencies must cooperate with the review to ensure that lessons are learnt and applied in future.
  • The involvement of individuals and family members should be recorded, including whether advocacy was used to support them.

Key findings and recommendations

What were the key findings?

The analysis of Safeguarding Adults Reviews showed that self-neglect was the most common type of abuse, followed by neglect/omission, physical abuse and organisational abuse. Certain forms of abuse were more common amongst people of certain age groups; for example, sexual abuse was more common amongst young people than older people.

There are five types of learning from the analysis:

  • how well the individual(s) and their family were safeguarded
  • how well practitioners and services worked together
  • in what ways the organisations providing services helped or hindered what took place
  • how the Safeguarding Adults Board supported the organisations to work together
  • the impact of legal rules, policies and financial resources at national level.

Key message: It is important that individuals, their relatives and friends, and their advocates know how to raise concerns about poor practice.

What were the findings about good practice with the individual and their family?

Some reports gave examples of good practice, for example:

  • how an individual’s health, care and support needs were met
  • how making safeguarding personal principles were applied
  • how services provided continuity of involvement.

Many, however, noted poor practice, for example:

  • Failure to assess mental capacity
  • Poor risk assessment
  • Failures to protect an individual
  • Poor recognition of carers’ needs
  • Inadequate attention to health, care and support needs
  • Practitioners taking things at face value rather than exploring.
Key message: Adult safeguarding should fully involve the individual who has experienced or is at risk from abuse or neglect (including self-neglect). Where safe to do so, the individual’s family and social network may have important contributions to make to reduce the risks and to provide support. It is important that individuals, their relatives and friends, and their advocates know how to raise concerns about poor practice.

What were the findings about what helps or hinders good practice?

Although there were some examples of good interagency practice, it was more common for shortcomings to be noted. Poor case coordination and information-sharing were present in almost three-quarters of cases.

In the agencies involved, there were pressures on staffing and workloads and shortages of resources. Managers sometimes were distant from decisions made. Staff sometimes had not had training, and guidance was missing.

Key message: These things affect how practitioners work and make it more difficult for safeguarding to be effective. Individuals and their advocates, relatives and friends will recognise when the service being offered is inadequate or poor. When they raise concerns, these should be addressed promptly and in a person-centred way.

Learning and applying lessons

When a Safeguarding Adults Review has taken place, the Safeguarding Adults Board should make sure that the lessons learnt are shared with all the services involved through reports, briefings, summaries and discussions. There should be an action plan setting out how the review’s recommendations will be met, and updates on progress should be available.

Key message: It is important that individuals, relatives and advocates can see how lessons are being learnt from Safeguarding Adults Reviews.

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 Adult Reviews are carried out
  • a central place to store all Safeguarding Adult 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 an individual who may have experienced adult safeguarding, you will know whether or not you felt that your concerns, wishes and feelings were heard and recognised, and whether your desired outcomes were central to how practitioners worked with you. Did you feel safer as a result? Did you feel that the services you were offered were excellent, satisfactory, poor or inadequate? Your feedback and contributions are important if services are to improve.

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