Briefing for practitioners - Analysis of Safeguarding Adults Reviews

This briefing summarises key findings from the landmark study ‘Analysis of Safeguarding Adult Reviews (SARs) April 2017 – March 2019’, with particular reference to professional practice in direct work with the individual at risk of abuse and/or neglect. It is therefore of particular relevance to the work of practitioners and others who have frontline contact with individuals. It aims to support practitioners to apply best practice in their direct work and thus achieve positive outcomes in adult safeguarding.



What is a Safeguarding Adults Review (SARs)?

Under the Care Act 2014, sections 44(1), (2) and (3), Safeguarding Adults Boards (SABs) must carry out a Safeguarding Adults Review (SAR) 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 SAB may also (section 44(4)) undertake a SAR in other cases concerning adults with care and support needs. The purpose is to identify learning that can drive change that will prevent harm occurring in future similar circumstances.

Key messages regarding safeguarding adults

What were the key findings of the national analysis of Safeguarding Adults Reviews (SARs)?

This study analysed the findings of 231 Safeguarding Adults Reviews (SARs) completed over the 2-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.

The learning that emerged is spread across five domains of adult safeguarding: direct work with the individual(s) concerned; interagency collaboration; organisational features within the agencies involved; SAB governance; and the national legal, policy and financial context.

Key message: Shortcomings in practice have an immediate and direct impact upon the individual, and there is important learning for practitioners to apply to their own direct work. It is also the case that features in the other domains – resources and time pressures, information-sharing, case coordination, poor guidance and aspects of the national legal and policy context – can impact on direct practice. It is important that practitioners are alert to this and escalate concerns about ways in which their own effectiveness may be compromised.

What were the findings about direct practice?

The SAR reports focused both on good practice and on practice shortcomings, although comments on the latter were much more prevalent. The most commonly noted good practice related to how an individual’s health needs were met and the application of Making Safeguarding Personal principles, each noted in around 25 percent of cases. Also commended were continuity of involvement, attention to care and support needs, safeguarding practice and attention to mental capacity, each noted in around 15 percent of cases.

The most commonly noted practice shortcomings were a 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/support needs and healthcare needs were each present in over 40 per cent of cases. An absence of professional curiosity meant that circumstances were sometimes taken at face value rather than explored sufficiently to reveal an accurate picture.

Most frequently mentioned good and poor practice themes

Most frequently mentioned good practice themes

No. of mentions

Most frequently mentioned poor practice themes

No. of mentions

Responding to health


Mental capacity




Risk assessment








Working with carers






Mental capacity


Responding to health



Key message: When working with an individual, it is important that practitioners pay close attention to mental capacity, carrying out capacity assessments where indicated, particularly where an individual consistently disregards high levels of risk to themselves or others. The potential impact of impaired executive brain function on decision-making may also need to be considered.

Key message: Explicit and comprehensive risk assessment is an essential component of practice, as is a focus on proportionate risk management.

What were the findings on the wider 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 feature was pressure on staffing and workloads, present in over a quarter of cases. Absence of management scrutiny and of training were also noted, along with an absence of available resources, in some cases reflecting commissioning practice. In terms of SAB governance, a few reports noted an absence of guidance; examples included lack of policies on self-neglect, escalation, risk and mental capacity. 

Key message: Factors such as poor case coordination and information-sharing, pressures on staffing and workloads, availability of commissioned resources, and absence of management scrutiny, training and guidance, 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. Practitioners’ awareness of these systemic factors can assist them to take appropriate actions, for example to contribute actively to interagency coordination and information-sharing, and to escalate difficulties to the appropriate domain.

Learning and applying lessons

When a SAR has taken place in their locality, practitioners can expect to see the learning being disseminated by the SAB and by their own employer. SAR 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 practitioners learn the lessons from Safeguarding Adults Reviews, both in their own locality and elsewhere, and draw on this developing evidence base to inform their own practice.

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 a frontline practitioner, you are in a position that has huge potential to make a difference to the outcomes of safeguarding for the individuals with whom you work. Awareness of the most frequent pitfalls in direct practice can guide the enhancement of your own practice.

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