Safeguarding Adult Reviews (SARs)

The purpose of carrying out a SAR is to:

• Establish whether there are lessons to be learnt from the circumstances of the case, for example, the way in which local professionals and agencies work together to safeguard adults at risk.
• Review the effectiveness of procedures and their application (both multi-agency and those of organisations).
• Inform and improve local inter-agency practice by acting on learning (developing best practice) in order to reduce the likelihood of similar harm occurring again.
• Bring together and analyse the findings of the various reports from agencies in order to make recommendations for future action.

A SAR should always be considered if:

• an adult has died (including death by suicide), and abuse or neglect is known or suspected to be a factor in their death or
• an adult has experienced serious abuse or neglect which has resulted in permanent harm, reduced capacity or quality of life (whether because of physical or psychological effects), or the individual would have been likely to have died but for an intervention and
• there is concern that partner agencies could have worked more effectively to protect the adult.
• A SAB may also arrange for a SAR in any other situation which involves an adult with needs for care and support living in its area.
• If the SAR criteria are not met but the relevant SAB feels that there are lessons to be learnt, an alternative review may be undertaken. 

Any agency or professional can make a referral for a SAR in any case where the criteria appears to be met.

Before referring, please read the Briefing Note on Safeguarding Adult Review Referrals to make sure all steps required are followed.  

Please discuss with your manager/senior manager or WSCC’s Safeguarding Service Manager prior to submitting the referral and consider contacting the WSSAB’s Support Team to discuss. Email: SafeguardingAdultsBoard@westsussex.gov.uk.

Please note that families must be informed of a SAR referral and it should be made clear to them that a SAR is not any of the following:

• another enquiry
• a process to apportion blame 
• a replacement for an agency's complaints process. 

Please explain it is about multi-agency learning and that a referral will be considered for what would be the most appropriate action going forwards and that it may not lead to a SAR.

Please note that referrers need to keep families updated, prior to a decision being made and inform them of the outcome of the referral, once a decision is reached.  

To make a referral, please use the Safeguarding Adult Review Referral Form and forward to the WSSAB Support Team. Email: safeguardingadultsboard@westsussex.gov.uk.  

Reviews in West Sussex have predominately been regarding neglect and self-neglect.  17 areas for multi-agency learning have been identified to mitigate the risk of reoccurrence of similar deaths.  These are listed below and, grouped into four areas of practice which need improvement. Safeguarding best practice is underlined by following all relevant policies, procedures and protocols and includes practice which reflects learning from SARs, as well as case law.

1. Safeguarding practice including:

• Compliance with safeguarding policies and procedures
• Risk assessment
• Implementation of the Care Act
• Professional curiosity
• Information sharing
• Collaborative working
• Transitional pathways
• Health optimization

2. Safeguarding recording and quality including:

• Person-centred approaches and making safeguarding personal
• Understanding of differences between quality and safeguarding
• Monitoring of safeguarding concerns at low levels

 3. Self-neglect including use of the Mental Capacity Act

4. Safeguarding engagement and understanding including:

• Private and voluntary sector providers as part of a “system of care”
• Work with relatives to increase awareness of “what good looks like”
• Putting individuals needs first during times of operational pressures/crisis
• Transitional pathways

The National Safeguarding Adult Review (SAR) Analysis Project has developed various briefings for a range of audiences. The briefings have incorporated the research findings by examining published SARs, and identifying the learning required. 

Visit the policy and procedures section of the Safeguarding Adults Board website and click on Resources from the SAR analysis project to access the briefings.