Safeguarding Adult Reviews (SAR)

A Safeguarding Adults Review (SAR) is a review carried out to evaluate the practice of agencies involved with an adult (or adults) at risk, so that lessons can be learned, and practices improved.

Section 44 of the Care Act 2014 requires the Safeguarding Adults Board (SAB) to conduct a Safeguarding Adults Review (SAR) when the duty to do applies (a mandatory SAR) and permits them to arrange one in other circumstances (a Discretionary SAR). These are both explained in section 3 below.

The purpose of a SAR is not to proportion blame but to identify learning and decide how to apply this to future cases. The SAR should also be used to identify good practice.

The Safeguarding Adults Board

The following are the sole responsibility of the Safeguarding Adult Board:

1. Deciding whether there is a duty to conduct a SAR; and
2. If so, deciding the manner most appropriate and proportionate to carry it out; and
3. Making the necessary arrangements.

If the Safeguarding Adults Board decides there is no duty to conduct a SAR; they must decide whether there is still a value to carrying out a SAR. If there is, they must decide the most appropriate and proportionate manner to do so and make the necessary arrangements.

Note: The decision about whether a SAR should be carried out, and how best to do so lies solely with the Safeguarding Adults Board and cannot be made by any other organisation.

All other organisations and individuals

All organisations and individuals should be aware of the circumstances in which SAR referral must be made, and take the necessary steps to make a referral when those circumstances apply. If this is unclear, a referral should be made for the SAB to decide upon.

Where a decision is made to carry out a SAR (either mandatory or discretionary), any organisation or individual asked to co-operate with or contribute to the process must do so.

All SARs are subject to the six key principles that underpin all adult safeguarding work:

1. Empowerment;
2. Prevention;
3. Proportionality;
4. Protection;
5. Partnership;
6. Accountability.

For more information about these principles, see: Six Key Principles that should underpin all Adult Safeguarding Work.

The following principles should also be applied:

1. There should be a culture of continuous learning and improvement across organisations that work together to safeguard and promote the Wellbeing of adults, identifying opportunities to draw on what works and promote good practice;
2. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;
3. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
4. Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed;
5. Families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively.

If the adult is still alive all of the overarching aims, duties, and principles of adult safeguarding apply.

See: Overarching Aims, Duties and Principles Procedure.

A mandatory SAR is a SAR that must be carried out because the duties set out in sections 44 (1), (2) and (3) of the Care Act 2014 apply:

1. There is a reasonable course for concern about how the SAB, its members or other persons involved worked together to safeguard the adult; and
2. The adult has died, and it is known or suspected that the death resulted from abuse or neglect; or
3. The adult is alive, but it is known or suspected that they have experienced serious abuse or neglect.

Note: It is irrelevant whether or not the adult is known to the local authority, or whether or not they are being provided with support or services to meet their care and support needs.

With regard to c. above, indicators that this condition is met could include:

• The adult would have been likely to have died but for an intervention;
• The adult has suffered permanent harm;
• The adult has reduced capacity or quality of life (whether because of physical or psychological side effects) as a result of the abuse or neglect.

A discretionary SAR is a SAR that is carried out when the absolute duty to do so (set out above) does not apply. Under Section 44 (4) of the Care Act SABs are able to arrange for a discretionary SAR to be carried out in any other situation involving an adult in its area with needs for care and support where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect, and can include exploring examples of good practice that can be applied to future cases.

Any agency or professional may refer a case that they consider meets the criteria for either a mandatory or discretionary SAR to be carried out as outlined above.

Bradford

Email:  BSAB@bradford.gov.uk or
Call: 01274 432736

Calderdale

Safeguarding Adults Review (SAR) - Calderdale SAB Case Consideration Request Form

City of York

Safeguarding Adults Review

Kirklees

Safeguarding Adults Review referral

North Yorkshire

NYSAB - Make a SAR referral

Wakefield

Safeguarding Adults Review (SAR) Referral Form

Remember: It is the sole responsibility of the Safeguarding Adults Board (SAB) to decide whether the conditions for carrying out any kind of Safeguarding Adults Review (SAR) have been met and to arrange for a SAR to be carried out.

All referrals should be reviewed by the Safeguarding Adults Board (SAB) to ensure that the conditions for carrying out a Safeguarding Adults Review (SAR) have been met. Decisions should be made in line with local processes and requirements.

The Chair of the SAB is ultimately responsible for making any final decision.

The decision to accept (or not to accept) the referral should be clearly recorded in line with local recording requirements.

Once a referral is accepted the SAB should appoint an appropriate individual to carry out the SAR.

The individual must have appropriate skills and experience which should include:

1. Strong leadership and ability to motivate others;
2. Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
3. Collaborative problem-solving experience and knowledge of participative approaches;
4. Good analytic skills and ability to manage qualitative data;
5. Safeguarding knowledge.

There will also be a need to address the budgetary requirements for undertaking the SAR.

Decisions about who should carry out the SAR should be made in line with local processes and requirements.

The referrer should be notified of the decision made.

In the event of a SAR referral being rejected, the rationale should be clearly recorded in line with local recording requirements.

The referrer should be notified of the decision made.

If the referrer is dissatisfied with the decision, they can discuss their concerns with the SAB or make a formal complaint.

Remember: It is the responsibility of the Safeguarding Adults Board to determine what process each SAR should follow.

The approach should be proportionate to the scale of the abuse or neglect that has occurred, the impact on the person and the level of complexity in the issues to be examined during the review.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of people who have died or been seriously abused or neglected.

The SAR should be completed within a reasonable period of time and in any event within six months of initiation, unless there are good reasons for a longer time period.

In all cases

The SAR Panel should ensure that all relevant persons are involved.

For example:

1. Professionals involved with the adult;
2. Organisations involved with the adult;
3. Family members;
4. Carer's (informal and paid).

In some cases, it may be deemed necessary to also involve the person who caused (or is suspected of causing) the abuse or neglect.

If the adult is alive

If the adult is still alive, they should be consulted on the level of their involvement. They can decline to be involved.

If the SAB or individual carrying out the SAR requests a person or organisation supply information to support the process, they have a duty to comply with that request under s45 of the Care Act.

All information sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

If the adult is alive there is a statutory duty on the local authority to ensure they receive the support they need to enable them to understand and/or participate in the SAR process.

If they are already in receipt of advocacy support under Section 67 of The Care Act, The Mental Capacity Act 2005, or the Mental Health Act 1983 it is appropriate to establish whether the existing advocate is able to provide this support.

Otherwise, the duty to appoint an advocate under Section 68 of the Care Act must be considered.

For further information about the duty to appoint an independent advocate see: The Duty to Provide an Independent Advocate.

Several SARs have identified discrimination as either leading to or being a feature of the abuse that subsequently led to the death of an adult at risk. The Safeguarding Adult Review (SAR) should therefore seek to establish any role that protected characteristics or discrimination may have had in both the abuse or neglect and the safeguarding response itself.

For further information see: Discriminatory abuse in Safeguarding Adults Reviews and Serious Case Reviews (part of LGA briefing).

Learning should be shared in line with local processes and requirements, and with regard to the circumstances of each report.

Any actions to be carried out should be recorded in an Action Plan. It should be clear which individual representative of the relevant agency/organisation is responsible for carrying out each action and in what timeframe. This individual will be accountable to the SAB for implementation of the actions allocated to them.

The Chair of the SAB is responsible for reviewing the Action Plan and monitoring progress of the actions.

The following information from each Safeguarding Adults Review (SAR) must be recorded in the annual SAB Report:

1. The findings of the SAR;
2. What actions have been taken (or will be taken) in relation to those findings;
3. Where a recommendation has not been implemented, the reason/s for that decision.

Annual reports can be access using the links below:

Bradford

Learning from Practice

Calderdale

Calderdale Safeguarding Adults Board

City of York

Safeguarding Adults Review

Kirklees

Kirklees Safeguarding Adults Board (KSAB)

North Yorkshire

NYSAB Annual Reports

Wakefield

Safeguarding adults from abuse