Briefing for senior leaders - 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 is of particular relevance to senior leaders across a range of agencies, who are members of a Safeguarding Adults Board (SAB), in meeting their safeguarding responsibilities. It also can be used by all senior managers across the partnership.


The briefing draws out the themes from the report and key messages that will support senior leaders to ensure there is correct oversight of Safeguarding Adults Reviews by Safeguarding Adults Boards, that learning from reviews is cascaded, that practice is improved, and that positive change can be achieved.


What is a Safeguarding Adults Review ?

Under the Care Act 2014, sections 44(1), (2) and (3), Safeguarding Adults Boards (SABs) must carry out a 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 to prevent harm occurring in future similar circumstances.

This study analysed the findings of 231 Safeguarding Adults Reviews (SARs) 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% of reviews), followed by neglect/omission (37%), physical abuse (19%) and organisational abuse (14%). 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.

Safeguarding Adults Review content 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 SABs 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 regarding safeguarding adults review

The report identifies inconsistencies and issues regarding SAR processes, decision making and quality. For example, there was inadequate recording of types of abuse and neglect, protected characteristics and also mental capacity assessments. The report identifies a cluster of sector-led improvement priorities regarding the commissioning and conduct of SARs.

Key message: It is good practice to check that your SAB has robust internal systems to provide high quality and consistent governance of SAB processes. It is important that your SAB understands and implements the relevant legislation regarding referral and commissioning of SARs, e.g. documented in the SAB Annual Report.

Wider implications

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

Key message: It is good practice to consider whether there learning from a local SAR that senior leaders should raise at a national level because it is about national policy or legal frameworks.

Quality standards    

Quality Markers  outline standards for SAR reports and processes of commissioning, management and dissemination to stimulate practice and service 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. Not all reports refer to the review’s terms of reference. 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 and service shortfalls need to be remedied.

Key message: It is important that Senior leaders ensure that SABs have robust internal systems to provide high quality and consistent governance of SAR processes. SABs should record how learning from SARs has been cascaded to all partners through dissemination of briefings and the evidence acquired that reviews have had the desired impact on practice and service provision.

Key messages regarding safeguarding adults

Practice improvement

The SAR reports focused both on good practice and on practice shortcomings. The most commonly noted good practice related to how 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/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 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

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: It is important that your SAB cascades learning from SARs to all partners through dissemination of briefings. It is important that learning is cascading in your own organisation; and that this learning is being supported through training and workforce development. It is important that you know it is being embedded, and that you know it has had the desired impact on practice. 

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

While good interagency practice was noted in a fifth of cases, shortcomings were widely noted - poor case coordination and information-sharing were present in 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 SAB governance, a few reports noted an absence of SAB guidance; examples included policies on self-neglect, escalation, risk and mental capacity.

Key Messages: 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. It is important to check that recommendations from SARs have been implemented in your organisation; and that your SAB partners have implemented their recommendations. It is important to check that these changes have been embedded and have achieved the desired results.

Learning and applying lessons 

Statutory guidance outlines expectations regarding the reporting and use of findings. SARs do not have to be published but SAB annual reports must provide details of SARs in progress and the findings and recommendations of completed reviews. They must 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. Subsequent annual reports should update on the outcomes that have been achieved. This study found that not all SAB annual reports comply with the requirements in the statutory guidance. 

Key message: It is important that Senior leaders ensure that SAB annual reports comply with the SAR reporting requirements in the statutory guidance, including improvements that have resulted. 

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 members of the SAB, your role includes seeking assurance from partners that you are all meeting your statutory responsibilities regarding safeguarding adults in the area. It is important that the SAB is effectively assured that practice, services and partnership working is improving as a result of learning from SARs.

The full report...