A Safeguarding Adults Board (SAB) must arrange for there to be a review of a case involving an adult in its area with care and support needs (whether or not the local authority has been meeting any of those needs) if:

1. There is reasonable cause for concern about how the SAB, members of it or persons with relevant functions worked together to safeguard the adult, and
2. either of the following conditions are met:

Condition 1 is met if:

1. the adult has died, and
2. the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it is known about or suspected there was abuse or neglect before the adult died).

Condition 2 is met if:

1. the adult is still alive, and
2. the SAB knows or suspects that the adult has experienced serious abuse or neglect.

A SAR for any other reason (Discretionary)

1. The circumstances do not meet either Condition 1 or Condition 2 (above)
2. The SAB should consider arranging for a SAR regarding an adult in Surrey with care and support needs.

The overall purpose of a Safeguarding Adult Review is to promote learning and improve practice, not to re-investigate or to apportion blame.
The objectives include establishing:

• Lessons that can be learnt from how professionals and their agencies work together
• How effective the safeguarding procedures are
• Learning and good practice issues
• How to improve local inter-agency practice
• Service improvement or development needs for one or more service or agency.

Anyone is able to submit a SAR Referral to the SAB (please note this is not a safeguarding concern referral to the local authority.) To report a safeguarding concern to the local authority  Concerned about an Adult; Surrey Safeguarding Adults Board.  At times this may include a joint review being commissioned by the SSAB/ Community Safety Partnership (CSP).

The SSAB has developed a Safeguarding Adult Review procedure (currently under review).

Published SARs can be found on our SAR page.

What is a DARDR?

Domestic Abuse Related Death Reviews (DARDR) (previously known as Domestic Homicide Reviews or DHRs) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Victims Act (2004).

DARDR are carried out by Community Safety Partnerships to ensure that lessons are learnt when a person has died as a result of domestic abuse, either by homicide or suicide. The purpose of a DARDR is to:

• Establish what lessons can be learned from the homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims.
• Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result.
• Apply those lessons to service responses including changes to policies and procedures as appropriate.
• Prevent domestic abuse and domestic homicides and suicides, and improve service responses for all domestic abuse victims and their children through improved intra and inter-agency working.

To assist the Community Safety Partnerships in undertaking this duty the Home Office published statutory guidance on conducting domestic homicide reviews.

Resources

Domestic Abuse Related Death Reviews | Healthy Surrey

Guidance for domestic homicide review chairs – support for families – GOV.UK (www.gov.uk)

Home – AAFDA

‘Agatha’ and ‘Nick’ (September 2025) – In relation to unexpected deaths.

This thematic SAR looks at suicide prevention, following the deaths of ‘Agatha’ and ‘Nick’.

Publication Statement

Thematic Report

‘Matthew’, ‘Paul’, ‘George’ and ‘Jon’ (September 2025) – In Relation to unexpected deaths.

This thematic SAR looks at hospital discharge for adults with co-occurring conditions, following the deaths of ‘Matthew’, ‘Paul’, ‘Jon’ and ‘George’.

Publication Statement

Thematic Report

‘Munro’ (September 2025) – In relation to an unexpected death.

This joint Safeguarding Adults Review (SAR)/ Domestic Abuse Related Death Review (DARDR) relates to a lady known as ‘Munro’.  ‘Munro’ Died in December 2021.

Runnymede Domestic Abuse Related Death Reviews

Publication Statement

‘Roy’ (August 2025) – In relation to an unexpected death.

Roy died in August 2020 of Bronchopneumonia, at the start of the Covid-19 pandemic. This SAR looks at the following learning themes:

• The impact of the Covid-19 pandemic and subsequent restrictions.
• Multi-Agency working, co-ordination, information sharing and use of language – The Interaction between Services.
• Dementia Awareness.
• Working with Family Members with caring responsibilities.
• Engagement.
• Mental Capacity and Best Interests decisions.

Publication Statement
Learning Summary

‘Bernard’ (August 2025) – In relation to concerns of an incident of patient on patient attack at a nursing home.

‘Bernard’ a resident at a care home with dementia and a recorded history of violence and aggression towards residents and staff, at the care home.

Publication Statement
Learning Summary

Please note that this is a historic case.

‘Simon’ (July 2025) – In relation to an unexpected death.

Mr J and Mr Y (January 2016) – In relation to an unexpected death.

Following an incident in a nursing home when a man with dementia (referred to as Mr J), assaulted another resident (referred to as Mr Y). Mr Y was taken to hospital where he died 3 days later.

Executive Summary

Mr D (July 2014) – In relation to a concern about how agencies worked together.

Mr D was 84 years old when he became known to statutory services in 2008. The adequacy of the care he received as he physically deteriorated and became doubly incontinent, the quality of assessments and associated planning and responsiveness to concerns raised.

Executive Summary

Mrs A (March 2014) – In relation to an unexpected death.

Mrs A was a talented musician who committed suicide after giving evidence in a historic sexual abuse trial in which a teacher and his wife were convicted of offences against her.

Publication Statement
Executive Summary

Mrs S (March 2014) – In relation to an unexpected death.

Mrs S was 75 years old when she was admitted to Intensive Care in East Surrey Hospital, and sadly passed away in June 2012.

Executive Summary

Gloria Foster (September 2013) – In relation to an unexpected death.

In January 2013, Reigate and Banstead locality team of Surrey County Council, Adult Social Care (ASC), was informed by the London Borough (LB) of Sutton of concerns notified by the UK Border Agency (Home Office) in relation to illegal immigrants working for Carefirst241.

Publication Statement
Executive Summary
SCR Report

CC (October 2010) – In relation to an unexpected death.

CC died in 2009 when he fell from a car park in Woking. He had sustained external trauma to his body as well as a self-inflicted injury to his upper chest. The Coroner gave the cause of death as suicide. CC had a diagnosis of paranoid schizophrenia with secondary cannabis abuse and a personality disorder. He was on an enhanced level of Care Programme Approach at the time of his death.

He was well known to partner agencies including SABP, Woking Borough Council and Surrey Police.
and to the probation service.

Executive Summary

0002 (July 2010) – In relation to an unexpected death.

0002 died aged 81 years in a house fire at her home in Surrey in November 2008. She had lived alone since her husband died in 2006 and was supported by her family. She suffered from Chronic Obstructive Pulmonary Disease (COPD) and mild to moderate dementia with the probable diagnosis of Alzheimer’s. She had been known to both adult social care and mental health services since 2005.

Executive Summary

0001 (June 2010) – In relation to a near miss incident.

A ‘near miss event in March 2008 within a supported living environment when A was stabbed by 0001 in what appeared to be an unprovoked attack

Executive Summary

HL (September 2008)

HL was born in 1949 and at the age of two years diagnosed as suffering from profound mental retardation. In 1956 he was further diagnosed with, “autism” and “psychosis”. As a result his communication skills are extremely limited and he has a history of severe challenging behaviour and self-harming.

Executive Summary

Self-Neglect Thematic Safeguarding Adults Review –Torbay and Devon SAB

During 2019 and 2020, the Torbay and Devon Safeguarding Adults Partnership (TDSAP) received notice of the deaths of six individuals in Devon who had died in circumstances amounting to self-neglect. The Partnership concluded that the circumstances in each case met the mandatory criteria for a Safeguarding Adult Review (SAR)[2]. Such a review must take place where an individual has died (or been seriously harmed), the death or harm is thought to result from abuse or neglect (including self-neglect) and there is cause for concern about how agencies worked together to safeguard the individual. The purpose is to identify learning that can be used to improve future interagency practice and prevent future deaths or serious harm in similar circumstances. Given the presence of self-neglect as a feature in the lives of all six people, the Partnership took the view that a thematic SAR, seeking to identify common learning, would provide a valuable window on any recurring, systemic issues that may require attention within local safeguarding practice.

Thematic Safeguarding Adults Review – Self Neglect – Devon Safeguarding Adults Partnership

Professional Curiosity and Organisational Learning in Oxfordshire

Learning from reviews and professional curiosity, highlighting systemic barriers, organisational culture, and recommendations for improving safeguarding practice.

Key Findings:
Findings highlighted high workloads, resource constraints, performance-driven cultures, lack of psychological safety, and fragmented multi-agency working as major barriers to effective learning and professional curiosity.

The research found that leadership and management support are pivotal, with supervision often experienced as a tick-box exercise; effective leadership should foster psychological safety, model curiosity, and invest in management development.

Frontline practitioners reported that training was often unengaging or inaccessible, with a disconnect between training content and practical application, and a lack of reflective follow-up in supervision.

Recommendations for Systemic Change:
Recommendations included creating a culture of openness and shared learning, co-producing policies with frontline staff, reforming learning systems, protecting time for reflection, and translating SAR recommendations into actionable points for teams.

Learning from Reviews & Professional Curiosity in Oxfordshire: Key Themes and Actions for Sustainable Change

Learning Lessons Workshop Oxfordshire SAB – April 2025

‘Paul’ – Kent and Medway Safeguarding Adults Board (September 2025)

‘Paul’ aged 59 when he died by suicide. Had several mental mental health issues as well as physical health issues. He was known to have care and support needs and he had received a support package.
He had a long history of amphetamine and alcohol misuse. He had been an inpatient in a SABP facility in Surrey prior to his discharge back to Kent.

Overview Report
Learning Briefing

Ms C – Enfield Safeguarding Adults Review (September 2025)

Ms C was a 57-year-old woman, from Northern Ireland, who died in her own home in October 2022. The North London Coroner confirmed cause of death as heart disease with Type 2 Diabetes as a secondary cause. Ms C had experienced discrimination and abuse due to her gender identity. This may well have contributed to her lack of trust in professionals. There were some good examples of Ms C being referred to specialist support organisations who in turn advocated for her. However, there were also examples where staff did not seem confident in talking about issues of gender identity and where Ms C expressed that she did not feel her needs or experiences of discrimination were recognised or understood.

Executive Summary

Carers Thematic – Enfield Safeguarding Adults Review (February 2025)

In 2022, Enfield Safeguarding Adult Board identified the experience of four people as collectively meeting the criteria required for a Safeguarding Adult Review (SAR) in line with the Care Act (2014) and the Care Act Statutory Guidance (2023).

Carers Thematic – Enfield SAB

Seven Minute Briefing

‘Una’ – Wigan Safeguarding Adults Review (March 2024)

Wigan Safeguarding Adults Board [‘WSAB’] commissioned a safeguarding adults review [‘SAR’] following the serious sexual abuse of a patient by her care coordinator and subsequent concerns regarding the way the responsible mental health trust supported her
recovery, and the manner in which the wider safeguarding partnership worked together to safeguard her.

Wigan SAB – Una SAR

‘Tom’ – West Sussex Safeguarding Adults Review (2024)

The review, published in 2024, identified important learning across agencies working with those living with a disability, particularly in relation to safeguarding, information sharing, controlling and coercive behaviour, disguised compliance, professional curiosity, and trauma-informed practice.

Safeguarding Adults Review in respect of Tom (PDF, 545KB).

This new resource features Tom talking through his story and highlighting key themes. Tom is keen to help staff understand the crucial role you play in identifying and responding to safeguarding for those experiencing exploitation and abuse.

We encourage all staff across statutory, private and voluntary sectors, including partners in health, education, housing, policing and community services, to watch the video and reflect on how the learning can shape your work.

Thematic Homelessness Review – Sunderland Safeguarding Adults Board (2025)

This is a thematic safeguarding adult review (SAR). It has been commissioned to learn from how agencies worked with four homeless people in Sunderland who were clients of Sunderland City Council’s Housing Operations Team and who died. The themed review is in line with the action
recommended in the joint ministerial letter to Safeguarding Adults Boards in May 2024, namely that consideration should be given to conducting safeguarding adult reviews where a person experiencing homelessness has died.

Sunderland-SAR-v5.pdf

‘Harry’ – A Joint SAR/DHR published by Bournemouth & Poole Safeguarding Adults Board and Poole Community Safety Partnership (2016)

A combined Safeguarding Adult Review and Domestic Homicide Review has been completed following the death of Poole resident, ‘Harry’ in May 2015 aged 22. The two perpetrators, named Karen and John throughout the review, were convicted of his murder and sentenced to life imprisonment

The report found that professionals had “the knowledge, legal means, and opportunity” to prevent the 2015 murder Harry, but did not take steps to do so (8.19 Final Report). Published last week, the report identified “a lack of watchfulness and alertness” in respect of Harry’s adult safeguarding plan, which was delayed and was not updated to reflect changes to his situation (8.8 & 9.36 Final Report).

The report highlights the following areas of important learning:

• Information sharing
• Risk assessment and management
• Mental capacity
• Engagement with the perpetrators
• The impact of social media
• Mate crime

Introduction to the Safeguarding Adult Review and Domestic Homicide Review into the death of ‘Harry’
Joint SAR and DHR Final Report into the death of ‘Harry’
Executive Summary of Joint SAR and DHR into the death of ‘Harry’
Synopsis of Learning for Harry
Learning from Harry SAR and DHR Easy Read version 

‘Zac’ – by The Safer Lincolnshire Partnership (2021)

Please see link to a Lincolnshire DHR which involved several Surrey health providers and Surrey Children’s Services. Both Victim and perpetrator had been Surrey Looked After Children.

DHR Executive Summary
DHR Overview Report

‘Joanna’, ‘Jon’ and ‘Ben’ – Norfolk Safeguarding Adults Board (2021)

‘Joanna’ was admitted to Cawston Park under S.3 of the Mental Health Act during Oct 2016, she died 17 months later at the age of 36.

‘Jon’ died 11 months after being admitted to Cawston Park at the age of 33.

‘Ben’ was 32 when he died 24 months after his admission to Cawston Park.

‘Joanna’ and ‘Jon’ originated from London boroughs. ‘Ben’ was from Norfolk. Their behaviour was known to challenge services and sometimes their families. ‘Joanna’ and ‘Jon’ had experienced several out-of-family-home placements. ‘Ben’ had lived with his mother for most of his life. Their placement at the hospital resulted from personal and family crises. It was the only placement which could be identified by ‘Joanna’s’ Clinical Commissioning Group (CCG) which had previously contacted 38 other services.

SSAB SAR Learning Briefing – Joanna, Jon and Ben

‘Damien’ – Somerset Safeguarding Adults Board (2017)

Damien had diagnoses of Asperger’s Syndrome and ADHD. He had a mild learning disability and misused a variety of substances, causing him to come into frequent contact with the police and mental health services.

SSAB SAR learnings -Damien

Learning from SARs: A report for the London Safeguarding Adults Board By Suzy Braye & Michael Preston-Shoot

This review considered the nature and content of 27 SAR’s commissioned and completed by London SAB’s since the implementation of the Care Act 2014 on 1st April 2015 up to the 30th April 2017. The learning identified related to four key domains of the safeguarding system which are listed below along with key areas for improvement

London SAB SAR learnings

Mendip House Published by Somerset SAB (2018)

The National Autistic Society (NAS) were the Registered Managers of Somerset Court Campus, a 26-acre plot with seven registered dwellings plus outreach and day services for adults with autism. Mendip House was one of the registered homes, providing accommodation and specialist support for six adults with autism.

In May 2016, personnel from Somerset Safeguarding team and the CQC became aware of incidents of bullying following anonymous reporting. Subsequently a review took place which identified;

• taunting, bullying, mistreatment and humiliation of residents;
• financial abuse;
• missing medication; and
• poor oversight of staff

SSAB SAR learning – Mendip House

Adult C published by West Sussex SAB (2018)

In April 2015, two male residents of the same care home in West Sussex, Adult C (30 years) and Adult D (63 years) were taken to the Emergency Department of East Surrey
Hospital. Both have profound learning difficulties, cerebral palsy and suffer from osteoporosis.

Each was subsequently found to have suffered fractures to a femur and were admitted to the hospital where they remained for several months before being resettled in different care homes.
Whilst the care home (Beech Lodge) was located in West Sussex, the placing authority for Adult C was Surrey County Council (Mole Valley).

The West Sussex Safeguarding Adults Board commissioned a joint Safeguarding Adult Review in July 2016 into the care of both Adult C and Adult D. The focus of this learning briefing focuses predominantly on the recommendations for Surrey in relation to Adult C, however it is also mindful of the wider findings in relation to the injuries to both vulnerable adults.

SSAB SAR learnings – Adult C West Sussex

Adult B Published by East Sussex SAB (2020)

The East Sussex Safeguarding Adults Board (SAB) published the findings of a Safeguarding Adult Review (SAR) following the death of a 94-year-old lady in September 2017, referred to as Adult B. The lady died in hospital of natural causes but, when admitted, was found to have 26 unexplained injuries including a fractured nose and jaw, as well as old and new bruising to her face, arms and legs. She was diagnosed with sepsis and pneumonia shortly after her arrival in hospital and she died eight days later.

SSAB SAR learnings – Adult B East Sussex

Analysis of SARS April 2017-March 2019

National Network of Safeguarding Adults Board Chairs – SAR Library