What is a Safeguarding Adults Review (SAR) in Health and Social Care

What is a Safeguarding Adults Review (SAR) in Health and Social Care?


Care Learning

3 mins READ

A Safeguarding Adults Review (SAR) is a statutory review process carried out when an adult with care and support needs dies or experiences significant harm, and it is suspected that abuse or neglect played a role in the incident.

This process is mandated under the Care Act 2014 and aims to identify learning to prevent future instances of abuse and neglect. Here’s a detailed explanation of SARs in health and social care:

Legal Framework

SARs are established under the Care Act 2014, specifically Section 44, which places a legal duty on Safeguarding Adults Boards (SABs) to conduct these reviews.


The primary objectives of a SAR are to:

  • Identify lessons to be learnt from the case.
  • Ensure these lessons are applied to improve future practice.
  • Prevent similar harm from occurring to other adults in the future.
  • Promote a culture of continuous learning and improvement across the organisations involved.

Criteria for Conducting a SAR

A SAR must be conducted if:

  • An adult in the local authority area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the individual.
  • An adult is alive but has experienced serious abuse or neglect, and again, there are concerns about the efficacy of multi-agency working to safeguard the individual.

The SAB may also choose to carry out a SAR in other situations where it believes there are valuable lessons to be learnt.

Scope and Methodology

The scope and methodology of a SAR can vary depending on the complexity and circumstances of the case. Generally, the review might include:

  • Chronological timelines from agencies involved.
  • Analysis of the decision-making processes followed by the agencies.
  • Interviews with those involved, including professionals and, if appropriate, the affected individual or their family.
  • Examination of organisational procedures and inter-agency communication.

Multi-Agency Involvement

SARs are inherently multi-agency reviews, meaning that various organisations that were involved with the adult in question, such as health services, social care, police, housing services, and others, collaborate to investigate and contribute to the review.

Findings and Recommendations

Upon conclusion of the review, the SAR will produce a report outlining:

  • Facts of the case.
  • A detailed analysis of where and how things went wrong.
  • Lessons learnt.
  • Recommendations for improvements in practice, policy, and inter-agency work.

Publication and Dissemination

While the detailed findings of a SAR may often remain confidential to protect the privacy and dignity of the adult and their family, an executive summary, or key findings are usually published. The SAB ensures that the lessons learnt and recommendations are disseminated to all relevant agencies to implement the needed changes.


It is crucial that SARs lead to tangible changes. Thus, SABs are responsible for ensuring that the recommendations are acted upon. This can involve:

  • Development or revision of policies and procedures.
  • Training and development initiatives for staff.
  • Strengthening of inter-agency collaboration and communication.


SABs are held accountable for initiating and overseeing SARs. They also ensure that the process is transparent and that all agencies involved are committed to improving safeguarding practices based on the review’s findings.

Importance of SARs

SARs are a vital part of the safeguarding framework as they not only offer a mechanism for understanding what went wrong in particular cases but also drive continuous improvement across the sector. By learning from adverse events, agencies can enhance their preventative measures, thereby fostering safer environments for vulnerable adults.


Conducting SARs comes with challenges, such as:

  • Coordinating across multiple agencies.
  • Ensuring timely and comprehensive information sharing.
  • Balancing transparency with confidentiality to protect individuals’ privacy.
  • Implementing the recommendations effectively across different organisations.

In summary, a Safeguarding Adults Review is a critical tool aimed at protecting vulnerable adults by learning from serious incidents involving abuse or neglect. It helps to pinpoint systemic issues and areas for improvement, encouraging a proactive approach to safeguarding that influences policy, practice, and inter-agency collaboration across the health and social care spectrum.

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