Safeguarding Adults Reviews (SARs) Reports

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


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


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 (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])


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 (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])

Executive Capacity – Learning Briefing


May 2022

Mrs I: key themes around two-way communication between hospitals and care homes, medical management, professional curiosity and personalised care.

Mrs I – Learning Briefing


March 2022

Stephen: key themes regarding working with families, impact of Covid-19, understanding legal frameworks, handling of complaints and safeguarding concerns, end of life care and transfer of care/funding arrangements.

Stephen – Learning Lessons Review – Overview Report

Stephen – Learning Briefing

Stephen – Learning Briefing – Information for Carers

Stephen – Learning Briefing – Information for Care Providers around Mental Capacity Act and Best Interest Decisions 


January 2022

Adult H: key themes regarding Self-Neglect in a care setting, impact of Covid-19, working with families, assessing needs, understanding self-neglect, dementia and the Mental Capacity Act.

Adult H – Learning Briefing


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