1. Introduction

The Care Act 2014  introduced duties and requirements of local authorities and partner agencies, in a number of areas, including safeguarding adults. It provides a legislative framework for those working in adult safeguarding. One of the requirements is for the local Safeguarding Adults Board (SAB) to arrange a Safeguarding Adults Review (SAR) when certain criteria are met.

A provider may be asked to participate in the SAR process where it relates to either an adult who has or is receiving a service from the provider, or in relation to a member of its staff.

2. Criteria

An SAB must arrange for a SAR to be conducted when an adult in its area dies as a result of abuse or neglect (which is either known or suspected), and there is concern that partner agencies could have worked more effectively to protect the adult.

A SAB must also conduct a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect

In the context of a SAR it would be considered that there was serious abuse or neglect where, for example:

  • the individual would have been likely to have died but for an intervention;
  • suffered permanent harm;
  • has reduced capacity or quality of life (whether because of physical or psychological effects).

A SAB can arrange for a SAR in any other situation involving an adult with needs for care and support.

The adult who is the subject of a SAR need not have been in receipt of care and support services for the SAB to arrange a review.

The SAB should be primarily concerned with deciding what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. A case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults.

A SAR may also be used to explore examples of good practice where this may 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.

In some instances, the adult subject to the SAR will still be alive. In such circumstances, the local authority must arrange, where necessary, for an independent advocate to support and represent an adult who is the subject of a SAR (see Independent Advocacy). Where an independent advocate has already been arranged under the Care Act 2014 or under the Mental Capacity Act 2005 then, unless inappropriate, the same advocate should be used. It is critical the adult is supported in what may feel a daunting process. A person who is thought to have been abused or neglected may be demoralised, frightened, embarrassed or upset; independent advocacy provided to help them be involved will be crucial.

See also Safeguarding Case Studies.

3. Purpose of a Safeguarding Adult Review

A SAR 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 to the adult in question. This is so lessons can be learned from the case and applied to future cases in order to prevent similar harm occurring again.

The purpose of a SAR is not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as the Care Quality Commision, the Nursing and Midwifery Council and the Health and Care Professions Council.

If individuals and organisations are to be able to learn lessons from what occurred, it is vital that the SAR process is trusted and is a safe experience for participants that encourages honesty, transparency and sharing of information in order to achieve maximum benefit. If individuals and organisations are fearful of the SAR process, their response will be defensive and their participation guarded and partial.

4. Incorporating Safeguarding Principles

The SAB should agree terms of reference for any SAR they arrange. These should be published and openly available.

When undertaking a SAR, records and reports should either be anonymised through redaction or consent from those who could be identified should be sought.

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

  • learning and improvement – there should be a culture of continuous learning and improvement across the organisations, identifying opportunities to draw on what works and promote good practice;
  • proportionality – the approach taken should be proportionate according to the scale and level of complexity of the issues being examined;
  • independent – they should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
  • involvement of professionals – 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;
  • involvement of families –  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.

5. Safeguarding Adults Review Process

The process for undertaking a SAR should be determined locally according to the specific situation and individual circumstances. No one model is applicable for all cases.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of adults who have died or been seriously abused or neglected.

A provider may be asked to contribute information, attend meetings and be involved in ensuring relevant points from agreed action plans and implemented (see also Section 6, Sharing Information with Relevant Bodies, Information Sharing and Confidentiality).

It is essential that the recommendations and action plans from a SAR are followed through by the SAB, and their progress closely monitored.

The SAB should ensure that there is appropriate involvement in the review process of professionals and organisations who were involved with the adult. The SAR should also communicate with the adult and, or, their family. In some cases it may be appropriate to  try to speak with the person who caused the abuse or neglect.

The SAB should aim for completion of a SAR within a reasonable period of time. This should usually be within six months of initiating it, unless there are good reasons for a longer period being required, for example, because of potential prejudice to related court proceedings. During the SAR process, every effort should be made to capture and learning points from the case about improvements needed, and to take corrective action as appropriate.

7. Findings from SARs

The SAB should include the findings from any SAR it conducts in its Annual Report. It should include a summary of actions  taken, or to be taken in relation to those findings.

All documentation the SAB receives from registered providers which is relevant to Care Quality Commission’s (CQC) regulatory functions will be given to the CQC.

SAR reports should:

  • provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence, if possible;
  • be written in plain English;
  • contain findings of practical value to organisations and professionals.

In the interest of transparency and disseminating learning, the SAB should consider publishing a SAR report whilst maintaining the confidentiality for those involved as appropriate.