Safeguarding Adults Reviews (SAR)

County Hall

The Surrey Safeguarding Adults Board will undertake a Safeguarding Adults Review (SAR) when the circumstance set out in the Care Act 2014 (s44) guidance are met:

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 of not it is know 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

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 (

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

    Published SARs

    Mary (July 2021) – In relation to an unexpected death
    Publication Statement from the SSAB Chair
    Executive Summary
    Full Report
    Learning from the Death of Mary – Questions


    Person 1 (November 2020) – In relation to a patient on patient attack at a nursing home.
    Publication Statement from the SSAB Chair
    Executive Summary
    SAR Report

    Sasha (Hampshire SAR) May 2020 – In relation to multi-agency working.
    SAR Report
    SSAB SAR learnings – Sasha. Review by Hampshire SAB

    Mr J and Mr Y (2016) – In relation to concerns of an incident of patient on patient attack at a nursing home.
    Executive Summary

    Mr D (July 2014) – In relation to an incident at home.
    Executive Summary

    Mrs A (March 2014) – In relation to suicide.
    Press release
    Executive Summary
    SCR Report -26.03.14

    Mrs S (March 2014) – In relation to a choking incident.
    Executive Summary

    Pre-Care Act 2014 – Serious Case Reviews (SCRs)

    Gloria Foster –  In relation to reablement services.
    Statement from the SSAB Chair
    Executive Summary
    SCR Report

    SCR 0001 –  In relation to a ‘near miss event’
    Executive Summary

    SCR 0002 – In relation to a house fire.
    Executive Summary

    SCR CC – In relation to a car park fall.
    Executive Summary

    SCR HL (September 2008) – In relation of care.
    Summary Report

    Other SAB Lessons Learnt Briefings

    SSAB SAR Learning – Joanna, Jon and Ben by Norfolk SAB

    SSAB SAR learnings -Damien. Review by Somerset SAB

    SSAB SAR learnings – A report for the London Safeguarding Adults Board by Suzy Braye & Michael Preston-Shoot

    SSAB SAR learnings – Mendip House

    SSAB SAR learnings – Adult C West Sussex

    SSAB SAR learnings – Adult B West Sussex

    National lessons learnt

    The Care and Health Improvement Programme (CHIP) safeguarding work-stream commissioned Suzy Braye, Michael Preston-Shoot and Research in Practice to undertake a review of SARs published in 2018/18 and 2018/19 to inform future priorities for sector led improvement in safeguarding adults’ practice.

    The full report, Analysis of Safeguarding Adult Reviews: April 2017 – March 2019, is lengthy and academic, reflecting the considerable work that has been undertaken, the range and depth of analysis. Six shorter targeted briefings have been developed to enable easier access to the wealth of information and guidance arising from this work, links to which can be found below;

    National SAR Library

    National Network of Safeguarding Adults Board Chairs