Safeguarding adult reviews (SAR)

We will order a safeguarding adult review (SAR) when an adult in the area dies as a result of abuse or neglect, known or suspected. The SAR will also review whether partner agencies could have worked better to protect the adult.

We are also required to arrange a SAR if we know or suspect that an adult in the area has experienced serious abuse or neglect.

Serious abuse or neglect, which will result in an SAR, can occur in the following situations: 

  1. Where a lack of care would have resulted in the death of the individual, had intervention not occured
  2. The adult in question has suffered permanent harm, reduced capacity or quality of life as a result 

We may also arrange for a SAR in other situations if it involves an adult with care and support needs.

What's involved

When conducting an SAR, we will be primarily concerned with establishing a ‘review’ process that will help us determine what actions we need to take to prevent future death or or harm. 

The review may, for example, provide useful insights into the way organisations work together to prevent and reduce abuse and neglect of adults. Or they maybe used to explore examples of good practice that will identify lessons that can be applied to future cases.

We will hold early discussions with the adult and their family and friends to agree how they wish to proceed. The subject of any SAR will not need to have been in receipt of care or support services for a review to be arranged.

SARs should reflect the six safeguarding principles. We will agree to Terms of Reference before proceeding. These will be published and openly available if appropriate.

SAR records can either be anonymised through redaction, or consent to use any names obtained from the individual in question.

The council and our partner organisations will apply the following principles to any SAR: 

  • we will apply a culture of continuous learning and improvement across all safeguarding organisations
  • we will pursue a drive to identify opportunities to improve and promote good practice
  • we will create a review approach proportionate in scale and complexity to the issues in question
  • we will appoint individuals independent to the organisation or individual under review to manage the investigation
  • we will encourage professionals to contribute their opinions to any review without fear of retribution for actions taken in good faith
  • we will encourage families to contribute to the review. We will keep them adequately and sensitively informed at every step of the process. 

SARs and learning reviews

In 2017 a North Somerset resident died as a result of self-inflicted injuries. Because person had many support needs and was involved with multiple agencies, the NSSAB decided to carry out a lessons learned review.

The lessons learned from this review led the Board to develop the below action plan.