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Safeguarding Adults Reviews (SAR)


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 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 (

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


The death of a loved one can be devastating. Bereavement is a common experience after losing someone close to you and can affect people in different ways.
For more information on bereavement please visit the Healthy Surrey website.

Published Safeguarding Adult Reviews

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

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

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;