6. Safeguarding Adult Reviews

Safeguarding Adults reviews (SARS)

Under the Care Act 2014, LSABs must arrange a SAR when an adult in its area dies as a result of known or suspected abuse or neglect, and there is concern that partner agencies could have worked more effectively to protect the adult.


LSABs must also arrange a SAR if an adult in its area has not died, but the LSAB knows or suspects that the adult has experienced serious abuse or neglect. In the context of SARs, something can be considered serious abuse or neglect where, for example the individual would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect. LSABs are free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.


The LSAB should weigh up what type of ‘review’ process will 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.


Early discussions need to take place with the adult, family and friends to agree how they wish to be involved. The adult who is the subject of any SAR need not have been in receipt of care and support services for the LSAB to arrange a review in relation to them.

Safeguarding Adult Review (SAR) Leaflet for Families and Carers


The following principles should be applied by SABs and their partner organisations to all reviews:

  • there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the wellbeing and empowerment of adults, identifying opportunities to draw on what works and promote good practice
  • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined
  • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed
  • professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; and
  • families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively

Prior to the Care Act 2014 which came into effect in April 2015, SARs were known as Serious Case Reviews.

Care and support statutory guidance

Notifying the LSAB of a potential review

We use an online hosting system to make notifications and manage the information required for four review types and these are:

  1. Serious Case Review (SCR) for children
  2. Local Case Review/Learning Lessons Review
  3. Best Practice Review
  4. Safeguarding Adult Review (SAR)

 To submit a notification to either Board the link is:


Guidance for completing a notification or submitting requested information is available: SCR/SAR Guidance

B&NES Domestic Homicide Reviews

Since 2011, the Bath and North East Somerset Council Responsible Authority Group (RAG)has had a responsibility for undertaking Domestic Homicide Reviews where the death of a person aged 16 or over has, or appears to have resulted from violence, abuse or neglect by a relative, household member or someone s/he had been in an intimate relationship with.

The purpose of a domestic homicide review is to consider the circumstances that led to the death and identify where responses to the situation could be improved in the future.  In doing this, professionals and agencies involved, such as the police, local authorities, health agencies/professionals, voluntary sector will progress any recommendations made by the review.

A multi-agency review panel is established for each review, and comprises members of local statutory and voluntary agencies, and is led by an independent chair.

See th elink below for furthe rinformation and published DHR reports:

B&NES SCRs (prior to Care Act 2015)

There were two serious case reviews (as they were then known prior to the Care Act 2015) in B&NES:

SAR John - July 2018

This Safeguarding Adult Review was commissioned by B&NES Local Safeguarding Adults Board (LSAB) following the death of a 75 year old man, John (not his real name), who died in April 2017 as a result of self-neglect, despite a long history of involvement of health and care professssionals. 

The full report can be found below:

Full Report - SAR John

The B&NES Local Safeguarding Adults Board has provided the following response to the SAR:

Board Response

A press release on the publication of this SAR can be found below:

Press Release

A Practitioner Briefing for anyone working with those that self neglect:

Practitioners Briefing SAR John

LSAB Stakeholder Event - Self Neglect - July 2018

The LSAB held a stakeholder event on the 16th July for 100 delegates to learn about the findings of SARs locally and nationally on self neglect, and in line with the recommendations of SAR John to promote the revised LSAB Self Neglect Policy and Escalation Protocol, to learn about the Mental Capacity Act and self neglect and the role of carers in supporting those who self neglect.

The slides are available below and we would welcome these being used as learning for individuals and staff teams:

SARs and Self Neglect Professor Michael Preston-Shoot

Revised Self Neglect and Escalation

'Keith's Story' - A personal story of Hoarding from Birmingham SAB

Mental Capacity Act and Self Neglect

Self Neglect and Carers  Professor Jill Manthorpe

Help for Hoarders  Website

clutter image rating scale Leaflet from Avon Fire and Rescue


SAR Jane - March 2019

Jane (not her real name) sadly died in September 2017. She was found at home by a sheltered housing officer alerted by neighbours who had not seen her for around 36 hours. Following Jane’s death a Safeguarding Adults Review (SAR) was set up by the Bath & North East Somerset Local Safeguarding Adults Board (LSAB) to consider health and care agencies’ engagement with Jane in the twenty two months prior to her death and how they had worked together to meet her needs.

The full report can be found below:

Full Report - SAR Jane

The B&NES Local Safeguarding Adults Board has provided the following response to the SAR:

Board Response

A press release on the publication of this SAR can be found below:

Press Release

A Practitioner Briefing for anyone working with those that self neglect:

Practitioners Briefing SAR Jane 


Other National SARs

  • SAR Colin - The briefing is being shared anonymously as there are a number of sensitive issues which has led to the Board in question doing all that they can to protect the identities of those involved whilst still sharing the learning.
  • SAR/DHR Harry - A Safeguarding Adults Review/Domestic Homicide Review for Bournemouth & Poole:

            Summary SAR/DHR Harry

            Full Report SAR/DHR Harry

  • Thematic review – South West Region SARS