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

There have been two recent serious case reviews (as they were then known) in 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: