Safeguarding Adult Review (SAR)

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7-Minute Briefing
Oldham Safeguarding Adults Board (OSAB) are pleased to share a 7-Minute Briefing about statutory Safeguarding Adult Reviews (SARs) designed to answer frequently asked questions such as what is a SAR? What is the purpose? When is one completed? And, how are partner agencies involved? Take a look here.

What is a Safeguarding Adult Review?
A Safeguarding Adult Review (SAR) is a multi-agency process that considers whether or not serious harm experienced by an adult, or group of adults at risk of abuse or neglect, could have been predicted or prevented.

Statutory Guidance published by the Department of Health and Social Care in relation to SARs notes that the purpose of a SAR is to: ‘promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases. SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again. Its purpose is not to hold any individual or organisation to account’. 

The Board’s Duty 
The Care Act 2014 introduced the core statutory duty of the Board to undertake a Safeguarding Adult Reviews, where an adult with needs for care and support has died and the death resulted from abuse and neglect or is alive and the Boards knows or suspects that they have experienced serious abuse or neglect. 

Importantly, Safeguarding Adult Reviews are about how agencies worked together to safeguard adults; they are in their nature multi-agency reviews. For a review to be mandatory in legislation, there must be reasonable cause for concern about how the Board, its members (or others with relevant functions) worked together to safeguard the adult. 

The Board are concerned with reviews of significant cases, some of which will become Safeguarding Adult Reviews and others may become reviews that will not meet the threshold but will be commissioned by the Board when considered necessary. The learning and recommendations from all reviews will be treated in the same way as a formal Safeguarding Adult Review. 

The Board’s Policy for conducting Safeguarding Adult Reviews can be accessed here.

Making a Referral for a SAR
Any agency can make a referral for a SAR if they identify a case where they believe that the criteria for a SAR are met.

Requests for a SAR must be made in writing using the OSAB Safeguarding Adult Review Referral Form.docx, which should be completed as fully as possible and returned to

Where a professional  has identified a possible SAR referral, the case should first be considered internally within the agency at the appropriate level. Each agency needs to decide how any SAR referral will be verified internally before the referral is made to OSAB. This process should be clearly communicated to staff and noted in any single agency safeguarding adults policy.

It is not currently a statutory requirement to publish Safeguarding Adult Reviews reports however, it is recognised good practice to demonstrate the level of transparency and accountability needed to enable lessons to be learned as widely and thoroughly as possible and to ensure that organisations adopt the learning and recommendations.

The Board must consider publication within the legal parameters about confidentiality and if publication could be deemed to be detrimental to the person’s wellbeing or the person. It is therefore the Board’s policy to determine approval for publication on a case by case basis and consideration is given to the specific details of each SAR. 

SARs are published both as a Seven-Minute Briefing and a more detailed summary report with recommendations for any changes to the way services are provided. Seven-Minute Briefings come from a technique used by the FBI. They are based on research which suggests that seven minutes is an ideal time span to concentrate and learn. It also means that the briefings can be easily incorporated into regular meetings to help teams reflect on their practice and support learning. 

Published Review Documents
Safeguarding Adult Reviews and Seven-Minute Briefings are published below as they are completed.

SAR Jason
OSAB SAR Jason Overview Report.pdf

SAR Robert
OSAB SAR Robert Overview Report.pdf
7-Minute Briefing

SAR Derek
OSAB SAR Derek Overview Report.pdf
7-Minute Briefing

SAR Sarah
OSAB Discretionary SAR Rapid Review Report - Sarah.pdf

OSAB SAR Sam Overview Report.pdf

SAR Miriam
OSAB SAR Miriam Overview Report.pdf

SAR Jessica
OSAB SAR Jessica Executive Summary.pdf
7-Minute Briefing

SAR Amanda
OSAB SAR Amanda Executive Summary.pdf

SAR Steven
OSAB SAR Steven Overview Report.pdf

SAR Vince
OSAB SAR Vince Overview Report.pdf
7-Minute Briefing

Thematic SAR (Self-Neglect with Substance Misuse and Multiple Exclusion Homelessness)
Thematic Review Executive Summary.pdf
Safeguarding and Self-Neglect 7-Minute Briefing.pdf

All media enquiries relating to the publication of SARs should go to the Board Business Unit in the first instance:

Published SARs from other Local Safeguarding Adults Boards
Manchester Safeguarding Partnership SAR Olia and Baby W 
MSP SAR Olia and Baby W Report

National Analysis of SARs
This first national analysis of SARs completed between April 2017 and March 2019, in England, was funded by the Care and Health Improvement Programme, supported by the Local Government Association and the Association of Directors of Adult Social Services. Its purpose was to identify priorities for sector-led improvement. An Executive Summary of the report can be found here. The report is available here.

All content © 2024 Oldham Safeguarding Adults Board

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