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Safeguarding Adult Reviews (SARs)

The Care Act states that the safeguarding adults board must arrange a safeguarding adults review in some circumstances – for instance, if an adult with care and support needs dies as a result of abuse or neglect and there is concern about how one of the members of the safeguarding adults board acted.

The reviews are about learning lessons for the future. They will make sure safeguarding adults boards get the full picture of what went wrong, so that all organisations involved can improve as a result.

The purpose of a safeguarding adult review is not to re-investigate or to apportion blame. It is to:

  • Establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults with care and support needs;
  • Review the effectiveness of procedures (both multi-agency and those of individual organisations);
  • Inform and improve local inter-agency practice;
  • Improve practice by acting on learning (developing best practice); and
  • Prepare or commission a report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action.

There is no requirement for a case to have gone through a Section 42 safeguarding adults enquiry before it can be considered for a SAR. However, there should be multi-agency involvement in the case and a likelihood that multi-agency learning can be identified.

A SAR may be arranged by NYSAB for any other case involving an adult in its area with needs for care and support. A non-mandatory SAR should only be commissioned when it is clear that there is potential to identify sufficient and valuable learning to improve how organisations work together, to promote the wellbeing of adults and their families, and to prevent abuse and neglect in the future where the case does not fully meet the criteria for a statutory SAR.

Appropriate cases for a non-statutory SAR may include:

  • Serious incidents with multi-agency involvement that do not meet the criteria for a statutory SAR but that NYSAB wants to review as it is likely that multi-agency learning can be identified.
  • A case featuring repetitive or new concerns which NYSAB wants to review in order to pre-emptively tackle practice areas or issues before serious abuse or neglect arises; or
  • A case featuring good practice in how agencies worked together to safeguard an adult with care and support needs, from which learning can be identified and applied to improve practice and outcomes for adults.

Safeguarding Adults Review Policy

This document provides guidance on the North Yorkshire Safeguarding Adults Board (NYSAB) Safeguarding Adult Review (SAR) Framework. It is designed to assist people to decide when to refer a case for consideration as a SAR, as well as providing guidance on the SAR process itself.

SAR Policy

Referral Form

Published Reviews

The published reports and accompanying documents of the statutory and non-mandatory SARs commissioned by the NYSAB can be accessed via the links in the drop down menu below.

The full SAR report in respect of Elaine can be viewed here: https://safeguardingadults.co.uk/sar-elaine

The SAR executive summary report in respect of ‘James’ can be viewed here https://safeguardingadults.co.uk/sar-james

This review looks at the circumstances surrounding the closure of a care home in the Vale of York area of North Yorkshire in August 2020. The review looks at the period immediately before the national lockdown, the time from the date of lockdown until agencies were actively involved in responding to serious concerns around quality in the home and the arrangements around supporting people to move and the closure of the home.

The report makes a number of recommendations to the individual agencies involved and the SAB as a whole which are accepted in full. These actions have been incorporated into an unplanned care home closure action plan. This is a plan that incorporates any learning from care home closure to ensure learning is shared and informs ongoing practice.

The report and unplanned care home closure action plan can be found here: https://safeguardingadults.co.uk/review-lo-care-home/

The full SAR report in respect of ‘Anne’ can be viewed, together with a response to the report from Anne’s family and subsequent comment from Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust here: https://safeguardingadults.co.uk/SAR-Anne

The SAR report in respect of ‘Ian’ can be viewed, together with a 7 minute briefing and delivery report here: https://safeguardingadults.co.uk/SAR-Ian

North Yorkshire Safeguarding Adults Board has recently been involved in a review concerning a 46 year old White British man with learning disabilities and other complex medical conditions (Mr K). The review was carried out using methodology used for Learning Disability and Mortality Reviews and was undertaken in partnership with Kirklees Safeguarding Adults Board and Leeds Safeguarding Adults Board.
The review found a number of areas of good practice of those who supported Mr K throughout his life. No abuse or neglect was identified. In contrast, the review identified positive partnership working in caring for Mr K and noted the dedication of those in North Yorkshire who worked with him.
Further information about the review and its findings can be found on the Kirklees Safeguarding Adults Board website at the following link: https://www.kirklees.gov.uk/beta/adult-social-care-providers/pdf/learning-from-a-recent-review.pdf

The lessons learned review and independent health review reports can be viewed, together with a response to the report from one of Mrs S’s daughters here: https://safeguardingadults.co.uk/llr-mrs-s/

The SAR report in respect of ‘Mrs A’ can be viewed, together with a 7 minute briefing here: https://safeguardingadults.co.uk/sar-mrs-a/

The serious case review in respect of ‘Robert’ can be viewed, together with a staff briefing here: https://safeguardingadults.co.uk/scr-robert/

The Alexander Court Lessons Learned Review is available to read and download here: https://safeguardingadults.co.uk/wp-content/uploads/2021/07/Lessons-learnt-from-Alexander-Court.docx

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