Safeguarding Adults Reviews (SAR)

County Hall

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

  • An adult has died as a result of abuse or neglect and there is a concern that partners could have worked together more effectively to protect the adult.
  • An adult has experienced serious harm as a result of abuse or neglect and there is a concern that partner agencies could have worked more effectively to protect the adult.

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

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 workstream 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