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Safeguarding Adult Reviews (SARs)

Safeguarding Adults Boards have a duty be assured that local safeguarding arrangements are in place as defined by the Care Act 2014 and statutory guidance.  Part of this duty is to carry out a Safeguarding Adult Review (SAR) when an adult at risk dies as a result of abuse or neglect, whether known or suspected, or is still alive but has experienced serious abuse or neglect and; there are concerns that partner agencies could have worked more effectively to protect the adult.

The purpose of a SAR is to promote effective learning and improvement action to prevent future deaths or serious harm occurring again. The aim is that lessons can be learned from a case and those lessons applied to future cases to prevent similar harm happening again.

Safeguarding Adult Review 7 minute briefing

Key themes arising from recent Walsall reviews

These included:

  • the need to embed a person centred approach to practice
  • full compliance with the care act legislation and mental capacity act, including undertaking capacity assessments and recording the outcome
  • the need to continuously try to engage with service users who present as ‘non compliant’ or ‘difficult’
  • quality monitoring of learning disability homes
  • inter-local authority protocol when individuals are placed in the local area by another local authority
  • the need to undertake sound risk assessments for long term conditions


The second national analysis of Safeguarding Adult Reviews (SARs) in England was funded by Partners in Care and Health, supported by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS). Its purpose was to identify priorities for sector-led improvement as a result of learning from SARs completed between 2019 and 2023, a period of time that included the Covid-19 pandemic.

The executive summary identifies the headline findings, drawing on the detail contained in three main reports.

Analysis of Safeguarding Adult Reviews: April 2019 – March 2023 (executive summary) | Local Government Association

The full reports are being finalised and will be published shortly.

Briefings available for: