Safeguarding adult reviews

A safeguarding adult review (SAR) is carried out when an adult 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 person at risk.

A SAR may also be conducted when a person has not died but it is known or suspected that they have experienced serious abuse or neglect, sustained a potentially life threatening injury, serious sexual abuse or serious or permanent impairment of health or development.

All relevant board agencies should contribute to the review, sharing information and implementing and disseminating the lessons learnt.

The SAR brings together and analyses the findings from individual agencies involved, in order to make recommendations for future practice where this is necessary and also highlights good practice.

Derbyshire Safeguarding Adults Board (DSAB) has a SAR sub group which meets quarterly to discuss and make decisions regarding new referrals, oversees current reviews and ensures learning is implemented from Derbyshire reviews into multi-agency practice. The group also monitors reviews from other safeguarding adults boards to ensure any relevant learning for Derbyshire is distributed.

Attached to this page is a leaflet for families, friends and carers to help explain the SAR process.

Learning from multi agency reviews

Multi agency learning reviews take place where the criteria set in the Care Act for a safeguarding adult review to be undertaken is not met, but where it is felt that there may be valuable learning for a number of organisations about the way in which they work together to safeguard adults with care and support needs.

Summary reports and recommendations from completed DSAB multi agency learning reviews are attached to this page.

The DSAB SAR sub group is responsible for overseeing the implementation of recommendations and providing assurance to the Board that this has been achieved.

Statement for publication of SAR18A learning brief

“Derbyshire Safeguarding Adults Board (DSAB) commissioned a Safeguarding Adult Review (SAR) in 2018 in accordance with the Care Act in relation to an adult we refer to as Lisa.

“The board agreed there was some potential learning for agencies in this case and that as a partnership we needed to explore the background and what led up to the circumstances facing Lisa.

“The SAR is now complete and in addition to a comprehensive report it was agreed that the writing of a learning brief outlining the background, findings, including good practice and next steps was required.

“The learning brief should be read and discussed amongst practitioners and be used as a ‘tool’ to understand cases of a similar nature and promote professional curiosity. Multi-agency training is an obvious opportunity for this to occur but individuals need to self-reflect too.

“The SAR process does not conclude with this publication and the board will continue to oversee progress in relation to the recommendations of the SAR. As independent chair I will hold partners to account to ensure we move forward and learn from Lisa’s case.

“I am pleased to hear that Lisa is making good progress and is receiving the support and care she deserves.

“I thank all those involved in the SAR process, especially the independent author who has sensitively sought to understand Lisa’s journey in order that we all can learn and have a better chance to prevent the neglect and abuse of future adults at risk.

“Please review and reflect.”

Andy Searle, independent chair, Derbyshire Safeguarding Adults Board.