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Safeguarding Adults Review

Lessons Learned

Safeguarding Adults Review Lessons Learned Locally
(SAR) Definition Escalation of Risk

In some cases it was apparent that professionals had
Safeguarding Adults Boards (SABs) must arrange a not identified the need, or had the opportunity due to
SAR when an adult dies either as a result of abuse or the absence of a method to do so, to escalate risk.
neglect, known or suspected, and there is concern
that partner agencies could have worked more Inter-Agency Working
effectively to protect the adult; or if an adult has not Lack of inter-agency co-operation and working was
died, but the SAB knows or suspects that the adult also a contributing factor in many of the notifications
has experienced serious abuse. and non-statutory reviews overseen.

……………………………………… Information Sharing

This continued to be a key feature in many cases, with
professionals unable to efficiently and effectively
share information with colleagues in other agencies.
SAR - Carol
Professionals from the SAR Sub-Group and the Chair ………………………………………
of the Board continued to oversee the delivery of the
SAR-Carol review until the report was published on 13
June 2017. There was considerable coverage in the Lessons Learned Nationally
media on that day, and the report went on to become
the most read document the Board has published,
which is helping ensure the lessons are being shared. Out of Area Placements and Provider Oversight
Two high profile SAR cases highlighted the potential
risks in placing adults into care outside of the local
area. In these instances this led to a lack of oversight
by the hosting authority, and a lack of supervision by

1,650 reads the placing authority.
SAR
Carol (31 March 2018) Risk Assessment and Police Referrals
In other high profile SAR cases a critical feature was
the lack of focus on risk assessment in relation to
adults in care homes. This was combined in some
The full report can be read here: homes with a failure to report serious sexual and other
https://www.tsab.org.uk/key-information/safeguarding- criminal behaviour appropriately to Police.
adult-review-sar-reports/

……………………………………... ………………………………………

SAR Notifications and Mental Capacity Act (MCA)

Non-Statutory Reviews Lessons learned from local and national cases also
highlighted the need to improve understanding around
Three new notifications were considered by the Board MCA Assessments.
and the SAR Sub-Group during the reporting period,
although none progressed to a SAR as they did not A summary of regional and national cases can be
meet the statutory criteria. viewed here: https://www.tsab.org.uk/key-information/
safeguarding-adult-review-sar-reports/
The group also continued to oversee the delivery of
actions linked back to seven historical, non-statutory
reviews or cases. Impact of the Work

Good practice was developed in response to some of The focus on learning lessons
these cases and shared with relevant agencies.
from serious cases of abuse is
The Board’s SAR Policy and Procedures can be helping to prevent further
accessed here: https://www.tsab.org.uk/key-
information/policies-strategies/ instances from occurring.

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