Safeguarding adult reviews (SAR)

Since the implementation of the Care Act in 2014, we have a statutory requirement to undertake Safeguarding Adults Reviews (SARs). These are commissioned when 

• there is reasonable cause for concern about how NSSAB members or other agencies providing services, have worked together to safeguard an adult and;
• the adult has died, and NSSAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died)

We might also commission a SAR if

• the adult is still alive, and NSSAB knows or suspects that the adult has experienced serious abuse or neglect.

A Safeguarding Adults Review (SAR) is a multi-agency review process which looks at what relevant agencies and individuals could have done differently to prevent harm or death from taking place.

The purpose of a SAR is not to apportion blame. It is to promote effective learning and to prevent future deaths or serious harm occurring again.

When conducting an SAR, we will be primarily concerned with establishing a ‘review’ process that will help us determine what actions we need to take to prevent future death or harm. 

The review may, for example, provide useful insights into the way organisations work together to prevent and reduce abuse and neglect of adults. Or they maybe used to explore examples of good practice that will identify lessons that can be applied to future cases.

We will hold early discussions with the adult and their family and friends to agree how they wish to proceed. The subject of any SAR will not need to have been in receipt of care or support services for a review to be arranged.

SARs should reflect the six safeguarding principles. We will agree to Terms of Reference before proceeding. These will be published and openly available if appropriate.

SAR records can either be anonymised through redaction, or consent to use any names obtained from the individual in question.

The council and our partner organisations will apply the following principles to any SAR: 

• we will apply a culture of continuous learning and improvement across all safeguarding organisations
• we will pursue a drive to identify opportunities to improve and promote good practice
• we will create a review approach proportionate in scale and complexity to the issues in question
• we will appoint individuals independent to the organisation or individual under review to manage the investigation
• we will encourage professionals to contribute their opinions to any review without fear of retribution for actions taken in good faith
• we will encourage families to contribute to the review. We will keep them adequately and sensitively informed at every step of the process.

Safeguarding adults review: learning from the circumstances of treatment and support for Colin

Published on 19 July 2023.

Safeguarding adults review: learning from the circumstances of the deaths of Abi and Kim

Published on 14 June 2023.

Safeguarding adults review of Stan, Charlotte, and Philip 2023

‘A thematic review: self neglect’ published on 13 March 2023.

Action plan 2017

In 2017 a North Somerset resident died as a result of self-inflicted injuries. Because person had many support needs and was involved with multiple agencies, the NSSAB decided to carry out a lessons learned review.

The lessons learned from this review led the Board to develop the below action plan.