Safeguarding Adults Reviews (SARs) Reports


January 2024

Bernadette: key themes on domestic abuse, substance misuse, self-neglect, professional curiosity, mental capacity and considering executive functioning, lack of consent and when to share information.

Bernadette – Safeguarding Adult Review Report

Bernadette – Learning Briefing

Bernadette Recorded PowerPoint (a training resource which can be shared with colleagues – please select the ‘slideshow’ option in order for the presentation to play). If you wish to edit this presentation for any reason, please contact [email protected])

November 2023

SK: key themes on multi-agency working, safeguarding, self-neglect in a care setting, mental capacity and supporting Autistic people.

SK – Safeguarding Adult Review Report

SK – Learning Briefing

SK – Recorded PowerPoint (a training resource which can be shared with colleagues – please select the ‘slideshow’ option in order for the presentation to play). If you wish to edit this presentation for any reason, please contact [email protected])


James: key themes on trauma, self-neglect, substance misuse, mental and physical health, safeguarding, multi-agency working, mental capacity and family/carer support.

James – Safeguarding Adult Review Report

James – Learning Briefing

James – Recorded PowerPoint (a training resource which can be shared with colleagues – please select the ‘slideshow’ option in order for the presentation to play). If you wish to edit this presentation for any reason, please contact [email protected])


April 2023

Adult K: key themes on self-neglect and fire risks, impact of Covid-19 and declining support, understanding and applying legal frameworks, safeguarding and making safeguarding personal.

Adult K – Safeguarding Adult Review – Executive Summary

Adult K – Learning Briefing

Adult K – Recorded PowerPoint


August 2022

Martin: key themes on communication with the adult, family and between health and social care, professional curiosity, discharge arrangements, mental capacity assessments, impact of Covid-19.

Martin – Learning Lessons Review – Learning Briefing


June 2022

Molly: key themes on learning from good practice, the safeguarding system and multi-agency approaches, adult sexual exploitation, trauma informed care, staff supervision and support, legal literacy .

Molly – Safeguarding Adult Review Report

Molly – Learning Briefing

Molly – Recorded PowerPoint


Mrs I (May 2022) Learning Briefing. Themes: two-way communication between hospitals and care homes, medical management, professional curiosity and personalised care.

Stephen (March 2022) Learning Lessons Review Report, Learning Briefing, Information for Carers, Information for Care Providers around Mental Capacity Act and Best Interest Decisions. Themes: working with families, Covid-19, handling complaints and safeguarding concerns, end of life care, transfer of care/funding arrangements.

Adult H (January 2022) Learning Briefing. Themes:  self-neglect, dementia and the Mental Capacity Act in a care setting, impact of Covid-19, working with families, assessing needs.

Adult F (September 2021) Learning Briefing. Themes: self-neglect, engagement, domestic abuse, substance misuse, trauma, professional curiosity, safeguarding, multi-agency coordination, need for assertive outreach and flexible approaches.

Adult D (March 2021) Learning Lessons Review Report, Learning Briefing. Themes: self-neglect, parity of esteem (physical and mental health needs), legal literacy including Mental Health Act and Mental Capacity Act, hospital discharge and planning, housing, professional challenge.

Adult C (May 2020) Learning Lessons Review Report, Learning Briefing. Themes: domestic abuse, self-neglect, alcohol dependency, multi-agency working and communication.

Josh (December 2019) Safeguarding Adults Review Report, Learning Briefing. Themes: self-neglect, mis-management of medication, homelessness, substance misuse, mental capacity, frequent attender at hospital, safeguarding and multi-agency communication between professionals and with family.

Carol (June 2017) Safeguarding Adults Review Report, Executive Summary and Board Response. Themes: young perpetrators, self-neglect, alcohol misuse and vulnerability to exploitation, dual diagnosis, legal literacy including Mental Capacity Act, multi-agency approach to complex and high risk cases.


SAR Reports and Learning Briefings are published on the TSAB website for a minimum period of 12 months following completion of the relevant action plan. Copies are also available national repository for SARs. To request copies of reports that have been archived, please email [email protected]


For Children Reviews please visit South Tees Safeguarding Children Partnership and Hartlepool and Stockton Safeguarding Children Partnership