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Safeguarding Adults Reviews (SARs)

Learning from Safeguarding Adults Reviews

The Care Act 2014 includes a requirement for Safeguarding Adults Boards to hold Safeguarding Adults Reviews in certain circumstances and for partners to co-operate in the process. Following the implementation of the Act, ‘Safeguarding Adults Review’ replaces the term ‘Serious Case Review’.

Safeguarding Adults Reviews (SARs) provide an opportunity to improve inter-agency working by identifying and disseminating learning from incidents, sharing best practice and ultimately better safeguarding adults at risk of abuse and neglect.

A Safeguarding Adults Review is a multi-agency process to consider whether or not serious harm experienced by an adult with care and support needs could have been prevented, it makes recommendations to minimise the risk of a repeat occurrence. The main aim is to ensure that learning is disseminated across all organisations to improve practice and to deliver better outcomes for people with care and support needs.

Please scroll down for individual cases.

 Image: Improving the quality and use of Safeguarding Adults Reviews

RiPfA and SCIE are pleased to announce a new piece of work commissioned by the Department of Health aimed at improving the quality and use of Safeguarding Adults Reviews (SARs).

The initial phase of work will run from March 2017 to March 2018 to draw together and develop an online library of open access resources on the SCIE website containing reviews, reports, guidance and tools to support practitioners working in safeguarding. National safeguarding networks will be involved to ensure that stakeholder views and knowledge are represented in the development of the resources.

The space will provide open access to SAR reports alongside a search function to support easy navigation. There will be analysis of the reports to identify trends and emerging issues, and translation of this analysis into user-friendly materials containing key messages for practice.

Overview of the SARs library project

The sector has long demanded a library of Safeguarding Adults Review (SAR) reports. The Department of Health has commissioned SCIE and RiPfA to develop this resource. The aim is to maximise the value of individual SARs through two different kinds of resource. One will support the quality of individual SARs and the other will enable more widespread and effective use of the learning from SARs. This will support a virtuous circle whereby as the quality of individual SARs goes up, it also supports their being used to better effect.

What are we doing?

In the use strand we will be:

  • bringing together all published SAR reports
  • developing a category scheme to make the SARs library searchable
  • producing a one-off collation of the learning captured in SAR reports
  • bringing together and signposting other SAR-related research

In the quality strand we will be:

  • adapting the Serious Case Review quality markers developed by SCIE, for adult safeguarding
  • producing a one-off report on the kind of learning SARs reports are currently capturing and how easy is it to identify

Who is involved?

The library is being developed jointly by Research in Practice for Adults (RiPfA) and Social Care Institute for Excellence (SCIE), working closely with colleagues from the sector.

RiPfA and SCIE are pleased to be working with the Social Care Workforce Research Unit (SCWRU) at King’s College London on this project. The work of the SCWRU on SARs and SCRs is funded by the Department of Health’s Policy Research Programme.

The SAR library project is designed to bring together, build on and add value to relevant SAR activity that colleagues are already undertaking. Resource development is involving SAB chairs, SAB managers and agency safeguarding leads.

Please find attached practice briefing that pulls together recommendations and actions for practitioners from a safeguarding adults review that was arranged by Liverpool Safeguarding Adults Board in relation to Ms B recently. 

This briefing should be shared with all relevant staff and  should be used to reflect on practice in order to continuously learn and develop and improve outcomes for service users.   If you have any queries or would like any clarification regarding this briefing please email: [email protected] 

MSAB SAR Practice Briefing 032018

Please find below some SARs that have been completed recently:

Knowsley SAR- Grace

She was taken to the hospital just before 4pm by her mental health support worker employed by 5 Boroughs Partnership NHS Foundation Trust (5BP). Grace had telephoned her support worker as she was in a ‘low’ mood and told her she had taken an overdose of non prescribed drugs the previous day.

Grace left A&E before being medically assessed and returned to her home but then returned to A&E around 7pm the same day. It was thought that she had left again (Grace had done this on a number of previous A&E visits). The police were alerted and visited Grace’s home address, where Grace’s boyfriend’s mother said Grace had been home but left again.

She was found lifeless in the A&E department disability access toilet at 8.20pm that evening.

The Coroner’s Inquest in spring 2014 confirmed that Grace had taken her life by hanging. Toxicology reports indicated that she had, “a high concentration of THC in the blood together with carboxyl-TH and the results suggest recent cannabis and/or cannabis resin use” Grace was known to be a long term heavy user of ‘skunk’ a strong form of cannabis.

A Serious Incident Review Inquiry (SIRI) conducted by Whiston hospital shortly after Grace’s death concluded that, “Grace’s whole (adult) life revolved around the risk of suicide and this has been extensively documented particularly in the 5 Boroughs Partnership NHS Foundation Trust records. The evidence from Grace’s history strongly supports the view that by her late teens her self-harming behaviour was strongly entrenched, which put her at high risk of suicide”.

Please click on the link below for the full Safeguarding Adult Review:

Serious case review in the case ‘Grace’

Rochdale SAR – Tom

This case is about Tom who was found dead at Address One on a day in spring 2016. Tom was a kind and caring man who once held a responsible position working within the charitable sector. Unfortunately, Tom began to misuse alcohol and his lifestyle changed. He lost his career, his long-term relationship ended and he began living on his own at Address One.

Tom began to associate with a group of men and women who had a similar lifestyle to his own and alcohol was a common bond. These people frequented Address One, some with the permission of Tom but others were not welcome and abused Tom’s hospitality. There is evidence they stole personal possessions from him and money from his bank account.

Tom was well known to statutory and voluntary agencies. He was well liked by those professionals who dealt with him. However, Tom’s lifestyle and the lifestyle of others who frequented Address One attracted notoriety. Agencies suspected Tom was being exploited by these associates; a safeguarding alert was made and two multi-agency strategy meetings were held.

Although some actions were taken by agencies, Tom was found dead by Lynsey. Greater Manchester Police launched a homicide enquiry and arrested Male A, a man who had recently started to frequent Address One. He was charged with Tom’s murder and pleaded guilty when he appeared before a Crown Court in autumn 2016. Male A received a term of life imprisonment and must serve a minimum of 21 years in prison.

Please click on the link below for the full Safeguarding Adult Review:

SAR Rochdale Tom

Worcester SAR- Lee Graham

Lee Graham was a white British young person with a diagnosis of severe learning disability, Down’s Syndrome and aspects of autistic spectrum disorder, e.g. some obsessional behaviours. He had communication difficulties, but by using a limited vocabulary and Makaton signing he was able to make his needs and choices known to the people who knew him well. Lee Graham was also diagnosed with epilepsy soon after birth, but had had no symptoms for several years. He was short-sighted and required glasses.

Lee Graham had close relationships with his family; his Mother, Father, Sister and Brother. Sadly Lee Graham’s Father died suddenly and unexpectedly in July 2011.

Lee Graham enjoyed sports; swing ball, basketball, football and swimming. He liked watching DVDs, particularly Only Fools and Horses, and listening to music, including The Black Eyed Peas.

Lee Graham’s experienced extreme anxiety and found change difficult. His behaviour could escalate quickly and become very challenging. Lee Graham could be reluctant to engage in physical activities, often being happier watching. If he did not want to do something it could be very difficult to persuade him otherwise. He had received long term treatment for his anxiety and stress with tranquillisers.

The Designated Nurse for Worcestershire and the Lead Reviewer visited the family in March and met with Lee Graham’s Mother, Sister and Brother. The purpose of the Case Review. They provided helpful background information regarding Lee Graham.

The family are concerned that obesity was a key factor in Lee Graham’s death and are keen to ascertain whether appropriate steps were taken to address his weight gain in the years before his death. Lee Graham’s Mother had raised her concerns with a number of professionals over the years, including the Consultant Psychiatrist, the Community Learning Disability Nurse and the Manager of the Residential Unit.

Please click on the link below for the full Safeguarding Adult Review:

Worcestershire SAR Lee Graham

Buckingham SAR- Miss T

This young woman, referred to as Ms. T throughout this report to ensure anonymity, was of Asian origin. She was born in Buckinghamshire and, it is believed, lived in the County for most of her life. She studied accounting at Bradford University and lived with her parents until sometime in 2014. At the time of her death, and as far as can be established, Ms. T was living alone, in a social housing tenancy.

Ms. T had a history of asthma, type 2 diabetes and mental ill-health (paranoid schizophrenia). She had been known to the local mental health services for several years and had also been supported by primary care. She was aged 34 at the time she was found deceased. It would appear from agency records that she was last seen in November 2015 but was found in an advanced state of decomposition some 3 months later. The cause of death could not be established.

Please click on the link below for the full Safeguarding Adult Review:

Bucks Miss T SAR

Buckingham SAR- Miss T

Adult Q was 74-year-old man who lived alone in a private rented dwelling. People who knew him painted a picture of a man who had lived a varied and exciting life, travelling the county, on the road – driving a lorry, or riding a traditional horse-drawn caravan, or on the canal network, travelling and living on a barge. During his life Adult Q had been married, and had a son. Adult Q lost contact with his wife and son after they moved away. Adult Q’s son was three years old at the time. Adult Q also had a sister who he used to regularly visit when she was in a nursing home until her death.

Adult Q settled in Buckinghamshire and became a part of the local village community. Adult Q had one particularly close friend, Ms Y, who he used to see very regularly, they went on trips, and he became part of Ms Y’s family – he was like a second father to her. Over time Ms Y began to provide Adult Q with a significant level of support, helping him to look after himself, and his home.

Adult Q had a diagnosis of Bipolar Affective Disorder and Ankylosing Spondylitis1 – a long term inflammatory condition affecting the joints of the spine, and later a diagnosis of Parkinson’s disease. Adult Q had close friends locally who he saw throughout the week, and who provided him care and support. Adult Q has also been described as an active member of his local church, attending the mobility group, a social café, and weekly church

Adult Q died on 6th April 2016. The cause of his death was noted by the coroner to be bronchopneumonia2, with associated severe kyphosis3 which was secondary to that ankylosing spondylitis. At the time of his death a number of agencies were involved with Adult Q in the context of his health and needs for care and support. Agencies also became involved in a crisis period, responding to an allegation of financial abuse, and concerns raised through his care provider and informal support networks, regarding his mental state, home environment, and behaviours of self-neglect.


Knowsley Protocol for Safeguarding Adults Review


Liverpool Protocol for a Safeguarding Adults Review


Sefton Safeguarding Adults Review Protocol


Wirral Safeguarding Adults Review Protocol