Table of Contents


Safeguarding Adults Board (SABs) are a statutory requirement under the Care Act 2014 and the main objective of a SAB is to assure itself that local safeguarding arrangements and partners act to help and protect adults who meet the criteria set out in part 1, section 43 of the Care Act 2014.

According to the Care Act 2014 an Adult at Risk is an adult (someone aged 18 or older) who:

  • has needs for care and support (whether or not the authority is meeting any of those needs),
  • is experiencing, or is at risk of, abuse or neglect, and
  • as a result of those needs, is unable to protect himself or herself against the abuse or neglect or the risk of it.

The Cambridgeshire and Peterborough Safeguarding Adult Partnership Board (CPSAPB) oversees and leads adult safeguarding across the locality and has a range of statutory duties that contribute to the prevention of abuse and neglect. This includes the duty to conduct any Safeguarding Adult Reviews (SARs) in accordance with part 1, Section 44 of the Care Act. SARs are reviews that examine the way agencies and individuals have acted when they have been involved with an ‘adult at risk’ (AAR).

This guidance provides professionals with a step by step guide to follow when undertaking or participating in a Local Safeguarding Adult Review. It describes the approach, order of events and related timescales whilst also highlighting the key statutory elements outlined in the Care Act 2014. It also outlines responsibilities for key people at every stage of the process and includes template documents and letters.

Purpose and Criteria for Safeguarding Adult Reviews

The purpose of reviews of serious AAR safeguarding cases, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of AAR. Understanding whether there are systemic issues, and whether and how policy and practice need to change, is critical to the system being dynamic and self-improving.

Reviews should seek to prevent or reduce the risk of recurrence of similar incidents. They are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose, including through employment law and disciplinary procedures, professional regulation and, in exceptional cases, criminal proceedings. These processes may be carried out alongside reviews or at a later stage. Employers should consider whether any disciplinary action should be taken against practitioners whose conduct and/or practice falls below acceptable standards and should refer to their regulatory body as appropriate.

Definition of a Safeguarding Adult Review

Under the statutory guidance of Section 44 of the Care Act 2014, there are three broad circumstances which considers when a SAR may take place. The guidance makes a distinction between those circumstances where the SAB must or may arrange a SAR.

The SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if:

  1. There is reasonable cause for concern about the SAB, members of it or other persons with relevant functions worked together to safeguard the adult; and
  2. Either
    1. The adult has died and the SAB 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


    1. The adult is still alive and the SAB knows or suspects that the adult has experienced serious abuse or neglect

A SAB may also arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs). SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

  • Level 1 (Statutory) SAR will be required for those circumstances in which the SAB must arrange a SAR
  • Level 2 (Discretionary) SAR may be conducted in any other situations

In cases where there is learning but the case does not meet the criteria for a SAR, the Safeguarding Adults Review group may recommend another form of review.

Each member of the SAB must cooperate in and contribute to the carrying out of a review under this section with a view to:

  1. Identifying the lessons to be learnt from the adult’s case, and
  2. Applying those lessons to future cases

Criteria for a Safeguarding Adult Review

The first criterion for determining whether a SAR should be conducted is in establishing whether the adult was in need of care and support services (whether or not the local authority was meeting any of those needs).

The eligibility threshold for adults with care and support needs is set out in the Care and Support (Eligibility Criteria) Regulations 2014 (the ‘Eligibility Regulations’). The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing.

In considering whether an adult has eligible needs for care and support, local authorities must consider whether:

  • The adult’s needs arise from or are related to a physical or mental impairment or illness
  • As a result of the adult’s needs the adult is unable to achieve two or more of the specified outcomes (which are described in the Care Act 2014 guidance sections 6.105 to 6.112)
  • As a consequence of being unable to achieve these outcomes there is, or there is likely to be, a significant impact* on the adult’s wellbeing.

*Significant impact is not defined and should be understood to have its everyday meaning.

The second criterion to be met is establishing a cause for concern about how the SAB, its member organisations, or other persons with relevant functions, worked together to safeguard the adult. A particular emphasis is the extent that they could have worked more effectively to protect the adult from the resultant outcome and therefore the potential for learning.

The third criterion involves an examination of the link between the death (or other outcome) and suspected abuse or neglect.

In the context of SARs, something can be considered serious abuse or neglect where, for example, the individual would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life as a result of the abuse or neglect.

Approach and Principles

The purpose of conducting a Safeguarding Adult Review is, to establish whether there are any lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults at risk. The Safeguarding Adult Review brings together and analyses the findings from individual agencies involved in order to make recommendations for future practice where this is necessary.

Specifically the purpose of the Safeguarding Adult Review should:

  • understand what happened and why
  • learn lessons from the way professionals and agencies worked together
  • identify what the agencies and individuals might have done differently that could have prevented harm or death
  • prevent similar harm occurring in the future
  • improve future practice by implementing the learning
  • review and improve the safeguarding adults procedures
  • identify good practice
  • highlight any lessons that can be learned from the case and make a clear set of recommendations
  • ensure that relevant action is taken in order to help prevent future deaths or serious harm; this helps to improve both single and inter agency working and better safeguard and promote the wellbeing of adults at risk.

Families and significant others will be invited to contribute to reviews unless there is a strong reason not to. Steps will be taken to sensitively manage their expectations and ensure they understand how they are going to be involved.

Practitioners will be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.

All participants in the review process will be asked to declare any potential conflicts of interest and will be expected to sign, and adhere to, a confidentiality agreement.

The SAR should also consider how the principles of Making Safeguarding Personal (MSP) were applied; MSP means that safeguarding adults is:

  • person-led
  • is outcome-focused
  • engages the person and enhances involvement, choice and control
  • improves quality of life, wellbeing and safety

SARs will be undertaken in accordance with the six safeguarding principles:

  • Empowerment – every effort must be made to ensure the voice and lived experience of the adult at risk or their relatives is evident throughout the process.
  • Accountability – SARs should be trusted and safe experiences that encourage honesty, transparency and sharing of information and should be led by individuals who are independent of the case and of the organisations whose actions are being reviewed
  • Protection – SARs should seek to determine what the relevant organisations involved in the case might have done differently so that lessons can be learned and applied to future cases to prevent similar harm occurring again
  • Prevention – there should be a multi-agency culture of continuous learning and improvement to promote the wellbeing and empowerment of adults and identify and promote good practice
  • Proportionality – the approach should be proportionate according to the scale and complexity of the issues and the potential for learning
  • Partnership – there must be appropriate involvement in the SAR by professionals and organisations which were involved with the adult at risk

Information Sharing

The Safeguarding Adults Review should be viewed with consideration to Section 45 Care Act 2014 which outlines the expectation that organisations share information and be fully compliant in circumstances where information is required to enable the Safeguarding Adults Board to exercise its functions. Information should be shared in accordance with the Data Protection Act 2018 and General Data Protection Regulations (GDPR).

Information sharing is essential to safeguard and promote the welfare of adults at risk. Effective Safeguarding Adult Reviews are equally dependent on all relevant partners sharing the information they hold about the case and associated professional practice.

The Safeguarding Partners have the formal authority to request information to support both national and local Safeguarding Adult Reviews and the power to take legal action if information is withheld without good reason.

All agencies will be expected to share relevant information within the timescales requested. This may, when necessary, include sharing information without consent (such as where there is an ongoing police investigation).

Where a request is for health records this applies to all records of NHS commissioned care whether provided under the NHS or in the independent or voluntary sector.

When making requests for information, the Safeguarding Partners will consider their responsibilities under the relevant information law and have regard to guidance provided by the Information Commissioner’s Office.

Good practice principles around information sharing will always be followed, particularly around ‘how’ information is shared. For example, when responding to requests for information, agencies should:

  • Identify how much information to share; Distinguish fact from opinion;
  • Ensure that they give the right information to the right individual;
  • Ensure that they share information securely;
  • Where possible, be transparent with the individual, informing them that that the information has been shared (as long as doing so does not create or increase the risk of harm);
  • Record all information sharing decisions and reasons in line with organisational procedures.

In the case of any disagreement or failure to comply with a formal information request, the Independent Lead Reviewer or member of an Independent Review Team will refer the issue to the Case Review Subgroup who will seek to resolve this with the strategic Safeguarding Lead for the agency concerned. If a prompt resolution cannot be found, the issue will be escalated to the Safeguarding Partners for formal action.

Timescale for Completion of the Review

Reviews will vary in their breadth and complexity but in all cases learning should be identified and acted upon as quickly as possible. This includes before the review has formally commenced and while it is in progress.

Sometimes the complexity of a case does not become apparent until the review is in progress. For example, the police undertaking a criminal investigation may request a delay to the review due to involving specific key individuals. Any delays need to be considered by the relevant Case Review Subgroup as soon as they arise.

Making a Referral for a Safeguarding Adult Review

Any agency or individual (including a member of the public) can refer a case for consideration of whether it meets the criteria for a SAR. Only Cambridgeshire and Peterborough Safeguarding Adults Partnership Board (CPSAPB) can commission a SAR in Cambridgeshire or Peterborough.

Where any individual, including a member of the public or organisation believes or suspects there may have been circumstances where the threshold for holding a SAR has been met, the case must be referred to the Safeguarding Boards’ Independent Safeguarding Partnership Service to establish if there are important lessons for multi-agency work to be learned.

A referral is made by submitting a completed SAR referral form to the Safeguarding Boards’ Independent Safeguarding Partnership Service. Cambridgeshire and Peterborough SAR Referral Form

Referrals should be made as soon as it is apparent that the criteria for a SAR has been met. An unreasonable delay in raising any issue can impact on the process and the key purpose in a number of ways.

The SAB will not normally review cases which are more than twelve months old, unless there is significant information that has more recently emerged or there are good reasons why the SAR was not appropriate at an earlier stage. This is in order to ensure the optimum effectiveness and learning from the resources deployed.

By virtue of the criteria, in cases where a SAR may be initiated, a safeguarding concern and/or enquiry may already have been made. Consideration of whether a SAR is required should never delay the raising of a safeguarding concern and the adherence to the multi-agency safeguarding policy and procedures which considers any immediate protection required.

However, there may be circumstances where safeguarding concerns are not obvious or evident, for example, where the individual may have died as a result of suicide and there are concerns that partner agencies could have worked more effectively to protect the adult. In such circumstances a SAR referral should be submitted.

All agencies have their own internal or statutory procedures to investigate serious incidents and to promote reflective practice or learning, and this protocol is not intended to duplicate or replace these. However consideration of this protocol must be considered when agencies undertake internal reviews or when investigating serious incidents.

Where appropriate the referrer should ensure that their organisation is aware of the submission of the referral.

Decision Making for Implementing a Safeguarding Adult Review

On receipt of a SAR referral form, the Head of Service for the Safeguarding Partnership Board, or someone with delegated responsibility, will consider the information provided on the completed referral form. The Head of Service or a member of the Independent Safeguarding Partnership Service may seek further information including clarity about any parallel investigations that may be taking place.

The referral will be circulated to agencies on the SAR subgroup and other identified agencies for scoping information. This information will then be collated and presented at the next available subgroup meeting where all the information will be considered in order to decide whether or not a SAR should be held, and on application of the criteria, the level of review which is appropriate and proportionate in the given circumstances. The final decision is made by the Independent Chair of the SAR sub-group once all the available information has been considered.

Review Process

The Care Act 2014 guidance states that Partnership Board should aim for completion of a review within a reasonable period of time and in any event within six months of initiating it, unless there are good reasons for a longer period being required.

Once the decision has been communicated, each agency will be responsible for taking appropriate actions that may be necessary in relation to the security of their records. No member agency should comment publicly upon the case without express agreement of both their senior management and Independent Chair.

The Safeguarding Adult Review Process

Once the decision has been made that a SAR will be undertaken, a SAR Panel will be established on the basis that no member of the panel had immediate line management of the case under review, and should normally include representatives of the three SAB statutory agencies (Local Authority; Police; Clinical Commissioning Group). The panel and associated arrangements should be proportionate to the circumstances of the case and the review methodology.

For smaller scale reviews such as a multi-agency practice reviews, then the SAR subgroup may be the most appropriate panel.

The Safeguarding Adult Review Panel will set their own meeting schedule and timings appropriate to the case and the methodology used in the case; and report this to the Board. Whilst the frequency and number of meetings may vary, the SAR Panel will in most instances progress through the following three stage process, in order to establish; monitor and finalise the review:

If the Board requests information from an organisation or individual who is likely to have information which is relevant to SABs functions they must share what they know with the Board in accordance with the Care Act 2014.

Stage 1 – Establish

The Panel will have responsibilities from the outset to:

  • Specify the Terms of Reference (TOR) – which should always include reference to considering how the principles of Making Safeguarding Personal were applied
  • Set timescales for the period to be reviewed, if not already determined
  • Confirm the lead roles such as Chair, Facilitator, Author and the planned methodology to be used
  • Links to other interested parties such as the Crown Prosecution Service or Coroner
  • Coordinate and compile the available information including chronologies and reports of investigations that may have taken place
  • Confirm the agencies and the people involved and affected
  • Identify, inform and establish links to any other processes ongoing or planned
  • Where required, request that Independent Management Reviews (IMR) are completed
  • Identify any additional reports, information or evidence required
  • Agree the nature and extent of expert or legal advice required
  • Develop media and communications plans and with appropriate advice, publishing considerations
  • Consider how the adult, advocate and/or family can be involved in the SAR, including any issues relating to Duty of Candour
  • Set future panel meeting dates and times

Stage 2 – Monitor

During this phase the following functions are likely to be required of the Panel (with flexibility according to the methodology used and proportionate to the circumstances).

  • Maintain links with interested parties and parallel investigations
  • Produce a comprehensive chronology that covers that critical period collated from all agencies
  • Receive and scrutinise additional reports including IMRs and safeguarding/serious incident investigations
  • Cross reference information within the reports, identify any omissions or discrepancies
  • Conduct/commission any further enquiries
  • Examine and identify relevant action points
  • Form a view on practice and procedural issues
  • Identify critical points and actions with any key lines of enquiry
  • If the methodology requires a workshop or learning event, then this will be planned and delivered
  • Develop a framework for the report and consider drafts
  • Review progress and timescales and report to the SAB

Stage 3 – Finalise

During this stage, the members of the SAR panel will discuss and agree the key learning points of the review, the recommendations and actions required; and finalise the report. Once the SAR has been finalised at the SAR subgroup the SAR report is then sent to the Safeguarding Partnership Board for the final agreement of all partners and sign off.

Some of this work may be able to be undertaken outside of meetings, in which case panel members must commit to prioritise input and feedback to reports that are circulated within timescales.

On completion, the SAR report will be presented to the SAB which will:

  • Ensure contributing agencies have the opportunity to confirm the accuracy of facts and interpretation of their involvement in the report
  • Confirm the recommendations from the report
  • Confirm action plans, which should be endorsed at senior level by each organisation and agree accountability
  • Confirm to whom the review or parts of the review are to be made available (decisions on publishing will have been taken before completion of the review)
  • Commissioning the dissemination of the review of key findings to interested parties including feedback and debriefing to staff, family members and media
  • Confirm the arrangements to ensure that the actions are monitored and updates requested from agencies
  • Sign off the action plan when complete

Identifying and Consulting with the Adult at Risk, Family Members and Significant Others

Reflecting the principles of openness, transparency and candour, the SAB must ensure there is appropriate involvement in the review process of people affected by the case including where possible the victims of abuse and their families/significant others. In accordance with the Care Act 2014, where an adult has “substantial difficulty” in participating, this should involve representation and support from an independent advocate or their family member/friend where appropriate.

The SAR Panel must consider the degree to which the adult, advocate and/or their families will be involved in the review. The AAR, Family members and significant others, will be informed of the review and invited to contribute unless there is a strong reason not to do so. Consideration should also be given to if and how a known abuser might have some input to the review process. The initial planning meeting will discuss family involvement and agree an approach that will sensitively manage their expectations and ensure they understand the process.

Personal contact should be made whenever possible by the most appropriate professional and the family provided with a letter and/or leaflet to explain and introduce the process and the Lead Reviewer.

The AARs and their family’s engagement will normally be led by the Lead Reviewer so that the all views can be included alongside the analysis of professional practice.

It is recognised that the AAR and family members may decide not to take part in the review. All reasons for non-involvement of the AAR and family members (for example, parallel investigations or the choice of the individual) will be documented in the final report.

If an adult affected by a notifiable patient safety incident, has died or experienced serious abuse or neglect then a conversation with the family/adult should be considered prior to a referral for a SAR. If a SAR is commissioned subsequently then the family should be regularly updated on developments from the investigation into the patient safety incident and the SAR.

The AAR and their family may request sight of the information that has been gathered for the purposes of the review (agencies chronologies/ reports etc.). The partnership work to the principle that this information has been produced for the purposes of conducting a case review. The information (reports/ chronologies) remain the property of the agency that produced them and any requests for disclosure need to be addressed to each individual agency for their consideration. Agencies will consider sharing their information on a case by case basis, thought must be given to the impact of disclosure of information regarding other agencies practice that is contained within their reports.

Parallel Investigations

The case may also be subject to a criminal or coroner’s investigation, individual agency or professional body disciplinary procedures, and/or another type of formal review It is anticipated that a local Safeguarding Adult Review will go ahead unless there are clear reasons not to.

Coroners are independent judicial officers are responsible for investigating unnatural deaths and deaths of unknown cause and deaths in custody, all of which must be referred to the Coroner. The Coroner may have specific questions arising from the death of an adult at risk which are likely to fall in one of the following categories:

  • where there is an obvious and serious failing by one or more organisations
  • where there are no obvious failings but the actions taken by organisations require further exploration/explanation
  • where a death has occurred and there are concerns for others in the same household or care setting
  • deaths which fall outside of the requirement to hold an inquest but follow up enquiries are identified by the Coroner.

If HM Coroner contacts the SAB about any of the above situations the SAR Subgroup should give careful consideration as to whether a Safeguarding Adult Review be conducted.

Agencies should be aware that a request may be made by the Police or Court for chronologies/ reports to be disclosed when information is being gathered for a criminal case. If requested, the Independent Safeguarding Partnership Service will not provide a copy of your documents but will, instead, forward the agencies contact details to the Officer seeking disclosure so that direct contact can be made.

Legal Advice

Consideration will be given to whether legal advice will be required at the outset or during the review.


Taking into account the factors summarised above, the timetable for the review will be agreed. This will include the timing of Panel meetings, Learning Events and engagement with families.

Other Reviews and Investigations

The Care Act 2014 Statutory Guidance (14.176) requires that the CPSAPB must consider how the SAR will interface with other parallel processes or investigations. It is helpful to establish at the outset of the SAR all relevant areas which need to be addressed to reduce the potential for duplication. Important principles in planning include ensuring adherence to any separate statutory requirements, ensuring appropriate expertise and knowledge, reduction of duplication, maximising effectiveness and learning; and minimising the impact on those affected by the case. It is the responsibility of the Chair of the SAR panel to ensure that contact is made with the Chair of a parallel process. There are a number of types of review and investigation which may interface with a SAR and it is important to consider any other processes which may run parallel with the SAR or which may be being considered. These may include:

  • Child Safeguarding Practice Review (CSPR)
  • Domestic Homicide Review (DHR)
  • Safeguarding enquiry
  • LeDeR
  • Serious Incident Investigations (SI)
  • Mental Health Homicide Review
  • Disciplinary proceedings
  • Judicial Reviews
  • Complaints
  • Criminal Justice processes
  • Coroner’s Inquest

Where there are possible grounds for both a SAR and a CSPR or a DHR then a decision should be made at the outset by the respective decision making bodies as to how they will coordinate the reviews, engagement and report(s). This may result in some parts being jointly commissioned and overseen, or one board leading, with the same or different reports being taken to each commissioning body. This will necessitate a discussion between the Independent Chair and the Chairs of other panels involved in a review to consider how best to proceed.

All SARs needs to take account of a Coroner’s enquiry and any criminal investigation, including disclosure issues, which may impact on timescales. The Coroner must be informed of the decision to hold a SAR and the Chair of the SAR Subgroup must ensure that the necessary contacts are maintained with appropriate people.

Appointing the Lead Reviewer and Review Team

A Lead Reviewer will be appointed to manage the review process, chair meetings of the Review Team, facilitate information gathering workshops and author the final report.


The Care Act 2014 does not specify the methodology that should be used in local Safeguarding Adult Reviews but there is an indication that principles of a systems methodology could be taken into account by the Safeguarding Partners when agreeing the method by which the review will be conducted. This is similar to the CSPR as advocated by Eileen Munro.

Each case will, however, be examined individually and the methodology may be adapted to meet the specific needs of the case, to ensure a proportionate response, and to maximise learning to improve both frontline safeguarding practice and organisational structures. The Safeguarding Partners may agree to use a different methodology.

Agency Action and Expectations

All agencies which provided services to the AAR during the time period specified in the Terms of Reference will be formally requested to participate in the review process. The extent of agency engagement will be dependent on the type of review commissioned, the specific Terms of Reference and methodology chosen.

Each organisation should have an identified Safeguarding Lead to act as a single point of contact for the co-ordination and support of the review process.

Agencies should ensure that all requests for information are acted upon in a timely fashion and practitioners are released to participate in the review. Agencies should also provide support to their staff who are affected by the case where required.

Information Collection and Collation

Using the chronologies and/or analysis in the Information Reports, the Panel and IMR Authors will discuss the case in detail and develop the Key Themes. The key themes should identify issues of practice that have emerged within the case which can (i) be transposed into working with the AAR more generally and (ii) give insight into the systems which operate formally or informally within safeguarding practice.

The Overview Report

The Lead Reviewer will normally draft the formal report with publication in mind

Reports should meet any requirements specified in the agreed Terms of Reference for the review and, as a minimum, must include:

  • a summary of any recommended improvements to be made by persons in the area to safeguard and promote the welfare of the AAR
  • an analysis of any systemic or underlying reasons why actions were taken or not in respect of matters covered by the report

Reports should also include:

  • a brief overview of what happened and the key circumstances, background and context of the case. This should be concise but sufficient to understand the context for the learning and recommendations;
  • a summary of why relevant decisions by professionals were taken;
  • a critique of how agencies worked together and any shortcomings in this; whether any shortcomings identified are features of practice in general;
  • what would need to be done differently to prevent harm occurring to an AAR in similar circumstances;
  • examples of good practice; and,
  • what needs to happen to ensure that agencies learn from this case.

Any recommendations made should be clear on what is required of relevant agencies and others collectively and individually, and by when, and focussed on improving outcomes for AAR.

Reports should be written in a way that avoids harming the welfare of any surviving AAR in the case or identifying the individual. Information should be appropriately anonymised and very intimate and personal detail of the AARs life should be kept to a minimum to reduce the sensitivity of publication.

The Case Review Panel will be responsible for ensuring the draft report has met the agreed terms of reference, is succinct and focused on improving local safeguarding arrangements.

The final report should be formally approved by the Cambridgeshire and Peterborough Safeguarding Adult Partnership Board.


Upon completion of the Safeguarding Adult Review, the Safeguarding Adults Partnership Board will make the final decision on whether the SAR report will be published.

It is not currently a statutory requirement to publish Safeguarding Adult Reviews; however it is recognised good practice to demonstrate the level of transparency and accountability needed to enable lessons to be learned as widely and thoroughly as possible. It is therefore our policy that all reports are published in full unless:

  • publication could be deemed to be detrimental to the person’s wellbeing or
  • the person, or their family member(s) who act/acted in the persons best interests, ask for the report not to be published

Where a report is not published for these reasons, a practice briefing containing learning identified will be produced to ensure professionals are able to understand what happened and, crucially, what needs to change in order to reduce the risk of similar tragic events happening in the future.

If the review is to be published, Media and communication issues will be coordinated by Peterborough City Council or Cambridgeshire County Council Communications teams in collaboration with the Communications teams of other agencies involved to ensure consistency.

The wishes of the person subject to the review and their family will be considered as part of the publication and media planning. The proposed publication arrangements will then be discussed with the AAR and their family and appropriate steps will be taken to minimise the disruption and distress that any media attention surrounding the publication may cause to them.

The arrangements for informing practitioners will also be considered. It is likely that the senior managers from each agency will take responsibility for informing frontline staff of the date of publication and ensuring they have appropriate support.

A central point of contact for media enquiries should be identified. This individual can co-ordinate media enquiries during the publication phase and ensure effective liaison is maintained with each organisation’s strategic and press leads.

At the point of publication the Independent Chair of the SAR Subgroup will decide if a press statement is required, and if so, release a statement via the Communications Team outlining the reason for the review, the key findings and the required actions. The SAB and the Independent Chair of the SAR subgroup will retain discretion over the process and timing of publication taking into account such factors as ongoing criminal investigations or court proceedings

Published reports will always include the name of the reviewer(s) and may be made available to read and download from the Cambridgeshire and Peterborough Safeguarding Partnership Board website. Where full or executive reports are published these will be publicly available for at least one year and archived reports will be available on request from the Safeguarding Partners.

Capturing Improvements and Taking Corrective Action while the Review is in Progress

The Panel will consider at every meeting whether any immediate single or multi-agency action is required to respond to emerging issues identified through the review process. They may wish to deliver swift messages to the workforce in specific agencies or disseminate multi-agency learning to a wider workforce. In so doing, the Panel will consider what information is shared and whether this will have an impact on family members or any parallel investigations.

Disseminating and Sharing Learning from the Review

The Case Review Subgroup, or Training Subgroup, will be responsible for ensuring the identified improvements are implemented locally, including the way in which organisations and agencies work together.

A clear plan for disseminating and sharing the learning from the review with all relevant agencies will be developed. This may include organising single or multi-agency meetings, or producing briefing notes on the lessons learned for use in agency team meetings and/or supervision sessions.

It is the responsibility of the agencies who have participated in the review to ensure their agency recommendations are fully implemented and used to make improvements to their safeguarding children arrangements.

Annual Report

The findings from SARs will be included in the SAB’s Annual Report along with relevant service improvements and actions.

Monitoring Progress

The Case Review subgroup will regularly monitor progress on the implementation of recommended improvements, and will follow up actions to ensure improvement is sustained.

Taking into Account Learning from National Reviews

The Safeguarding Adult Review Group will also review the learning from all national reviews and consider how it can be applied at a local level.

Appendix 1 – SAR Referral Process Flowchart

Appendix 2 – Overview of Parallel Statutory Reviews

Effective local liaison is required between Multi-Agency Safeguarding Arrangements, Children Safeguarding Partnership Boards, Community Safety Partnerships and Multi-Agency Public Protection Arrangements to determine the most appropriate review process to maximise learning and minimise duplication of effort and reduce anxiety for families involved.

Summarised below is a brief outline of the main types of statutory reviews;

Child Safeguarding Practice Review

The Cambridgeshire and Peterborough Safeguarding Children Partnership Board oversees the commissioning of local Child Safeguarding Practice Reviews (CSPR). Where a case may meet the criteria for a SAR or CSPR liaison will take place between the Adult and Children Safeguarding Partnership Board’s to discuss primacy and agree the way forward.

Working Together 2018 defines serious child safeguarding cases as those in which:

  • abuse or neglect of a child is known or suspected and
  • the child has died or been seriously harmed

Serious harm includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health.

Domestic Homicide Review

Domestic Homicide Reviews (DHR) are commissioned by Community Safety Partnerships and overseen by the Home Office.

Section 9(3) of the Domestic Violence, Crime and Victims Act 2004 (the 2004 Act)1. The Act states:

A “domestic homicide review” (DHR) means a review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by—

  1. a person to whom he was related or with whom he was or had been in an intimate personal relationship, or
  2. a member of the same household as himself,

held with a view to identifying the lessons to be learnt from the death.

A DHR is undertaken to :

  1. establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
  2. identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result;
  3. apply these lessons to service responses including changes to inform national and local policies and procedures as appropriate;
  4. prevent domestic violence and homicide and improve service responses for all domestic violence and abuse victims and their children by developing a co-ordinated multi-agency approach to ensure that domestic abuse is identified and responded to effectively at the earliest opportunity;
  5. contribute to a better understanding of the nature of domestic violence and abuse; and
  6. highlight good practice. (Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (2016; p6))

The Multi agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (2016) states:

‘It should be noted that, when victims of domestic homicide are aged between 16 and 18, there are separate requirements in statutory guidance for child Serious Case Reviews, Safeguarding Adults Review and a Domestic Homicide Review. Consideration should be given to how these reviews can be managed in parallel in the most effective manner possible so that organisations and professionals can learn from the case – for example, considering whether some or all aspects of the reviews can be commissioned jointly so as to reduce duplication of work for the organisations involved and provide an improved experience for families, subject to the final shape of the review meeting the requirements of both as set out in the statutory guidance.’

For further information, see the Multi agency Statutory Guidance for the Conduct of Domestic Homicide Reviews (2016) Home Office.

DHR may also run alongside (in parallel) to any potential SAR or CSPR.

Multi-Agency Public Protection Arrangements – Serious Case Review

The purpose of the MAPPA SCR is to examine whether the MAPP arrangements were effectively applied and whether the agencies worked together to do all they reasonably could to manage effectively the risk of further offending in the community.

The chair of the MAPPA SMB has the responsibility to decide whether a case requires a MAPPA Serious Case Review (SCR).

It is a MAPPA SMB responsibility to commission a MAPPA SCR when the mandatory criteria have been met.

The SMB must commission a MAPPA SCR if both of the following conditions apply.

  • The MAPPA offender (in any category) was being managed at level 2 or 3 when the offence was committed or at any time in the 28 days before the offence was committed.
  • The offence is murder, attempted murder, manslaughter, rape, or attempted rape.

There will be other Serious Further Offences that may trigger a MAPPA SCR. It is difficult to prescribe discretionary criteria as much will depend on the circumstances of the particular case and whether there has been a significant breach of the MAPPA Guidance, but MAPPA SCRs might be commissioned when:

  • A level 1 offender is charged with murder, manslaughter, rape or an attempt to commit murder or rape
  • An offender being managed at any level is charged with a serious offence listed in PI 10/2011 or
  • It would otherwise be in the public interest to undertake a review, e.g. following an offence which results in serious physical or psychological harm to a child or vulnerable adult but which is not an offence listed in PI 10/2011

However, as a review of the lead agency’s management of the case will be conducted under these circumstances, careful consideration should be given to whether any value would be gained by conducting a MAPPA SCR for level 1 cases. This is especially relevant if cases have never been managed at level 2 or 3.

For further information, see MAPPA Guidance (2012) Ministry of Justice.

Other reviews may be triggered by the re-offending, for example:

  • Serious Case Reviews for Children – set out in Chapter 8 of Working Together to Safeguard Children (2010)
  • Domestic Homicide Reviews (Domestic Violence, Crime and Victims Act 2004).

These reviews do not specifically look at how agencies worked together under MAPPA but such a review may also be triggered by the offender’s re-offending. To avoid duplication and any misunderstanding, the MAPPA SMB must have in place a system of identifying whether any other review is taking place and of notifying other agencies when a MAPPA SCR is taking place.

Serious Incidents

Serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.

Serious Incidents in the NHS include:

  • Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:
    • Unexpected or avoidable death8 of one or more people. This includes –
      • suicide/self-inflicted death; and
      • homicide by a person in receipt of mental health care within the recent past (see Appendix 1);
    • Unexpected or avoidable injury to one or more people that has resulted in serious harm;
    • Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent:—
      • the death of the service user; or
      • serious harm;
    • Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where:
      • healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or
      • where abuse occurred during the provision of NHS-funded care.

This includes abuse that resulted in (or was identified through) a Child Safeguarding Practice Review (CSPR), Safeguarding Adult Review (SAR), Safeguarding Adult Enquiry or other externally-led investigation, where delivery of NHS funded care caused/contributed towards the incident.

  • A Never Event – all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death;
  • An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
    • Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues;
    • Property damage;
    • Security breach/concern;
    • Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population;
    • Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS);
    • Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services); or
    • Activation of Major Incident Plan (by provider, commissioner or relevant agency)
  • Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation.

Healthcare providers must contribute towards CSPRs and SARs (and enquiries) as required to do so by the Local Safeguarding Partnership Boards. Where it is indicated that a serious incident within healthcare has occurred, the necessary declaration must be made.

Whilst the Local Authority will lead CSPRs, SARs and initiate Safeguarding Enquiries, healthcare must be able to gain assurance that, if a problem is identified, appropriate measures will be undertaken to protect individuals that remain at risk and ultimately to identify the contributory factors and the fundamental issues (in a timely and proportionate way) to minimise the risk of further harm and/or recurrence.

The interface between the serious incident process and local safeguarding procedures must therefore be articulated in the local multi-agency safeguarding policies and protocols. Providers and commissioners must liaise regularly with the local authority safeguarding lead to ensure that there is a coherent multi-agency approach to investigating and responding to safeguarding concerns, which is agreed by relevant partners.

For further information, see Serious Incident Framework Supporting learning to prevent recurrence NHS England.

Independent Investigations for Mental Health Homicides

NHS England are responsible for commissioning an independent investigation of mental health care related homicides when a homicide has been committed by a person who is, or has been, subject to a care programme approach, or is under the care of specialist mental health services, in the past 6 months prior to the event.

The purpose of an independent investigation is to review thoroughly the care and treatment received by the patient so that the NHS can:

  • Be clear about what – if anything – went wrong with the care of the patient
  • Minimise the possibility of a reoccurrence of similar events
  • Make recommendations for the delivery of health services in the future

An independent investigation is carried out separately from any police, legal and Coroner’s proceedings. It is done by an independent, expert organisation, which is given access to all the information and reports about the individual patient’s care and treatment (within the usual patient confidentiality rules), and who can also request interviews with any NHS staff involved.

Local Authority Safeguarding Enquiries

Section 42 of the Care Act 2014 places a duty on the local authority to make enquiries when it has reasonable cause to suspect that an adult in its area has care and support needs, is being abused or neglected (or is at risk of being), and is unable to protect themselves because of their care and support needs.

The purpose of Section 42 enquiries is to enable the authority to decide what action needs to be taken to protect the person. It therefore does not apply to the situation where someone has died and may have been abused or neglected before that. As a matter of law an enquiry under Section 42 cannot be undertaken in relation to a person who is deceased. If the circumstances of the death mean that there are reasons to be concerned about risks to other adults, Section 42 enquiries may need to be made to decide whether action needs to be taken to protect them. For example, this could sometimes be necessary following a death in an organisational setting where other adults are continuing to receive a service.

If a SAR is being undertaken this DOES NOT replace a Section 42 Safeguarding Enquiry. If there are safeguarding concerns for an Adult at Risk a Safeguarding referral should be made to the local authority for consideration of a Section 42 Safeguarding Enquiry.

Learning Disabilities Morbidity Review (LeDeR).

The LeDeR panel review the deaths of people with learning disabilities aged 4 – 75 at the time of their death. All deaths will be reviewed, regardless of the cause of death or place of death, in order to:

  • Identify potentially avoidable contributory factors to the deaths of people with learning disabilities.
  • Identify differences in health and social care delivery across England and ways of improving services to prevent early deaths of people with learning disabilities.
  • Develop plans of action to make any necessary changes to health and social care services for people with learning disabilities

Appendix 3 – Models of reviewing cases

The process for undertaking Case Reviews should be determined locally according to the specific circumstances of individual cases. The most appropriate methodology will normally be that which provides the best opportunity to learn; however, it will be determined by, and be proportionate to, the specific circumstances and the scale of the situation.

Examples of different types of methodologies include:

Traditional Model

This methodology, is considered a traditional model, it was often used for child serious case reviews, domestic homicide reviews and historically in adult safeguarding. Typical features include:

  • Appointment of a panel, including a Chair (usually independent) and core membership which determines Terms of Reference and oversees process
  • Independent report author
  • Integrated chronology of events
  • Involved agencies produce Individual Management Reports, outlining involvement and key issues
  • Overview report with analysis, lessons learnt and recommendations
  • Relevant agencies produce action plans in response to the lessons learnt

Individual Management Reviews

Individual Management Reviews (IMRs) and Agency Reports are a means of enabling organisations to reflect and critically analyse their involvement, to identify good practice and areas where systems, processes or individual and organisational practice could be enhanced. They are key learning tools used in several methodologies and other similar reviews such as DHRs. They can be used in a multi or single agency environment.

It is important that individuals who are asked to undertake IMRs have the relevant skills and sufficient independence from the case being reviewed.

Where it is decided that IMRs are required:

  • The SAR Panel should write to the Chief Officer of the organisations involved, providing a template for an IMR
  • Organisational reports should be prepared by a senior officer and should provide a critical analysis of the organisation’s management of the case and identify the lessons learnt and actions taken or to be taken
  • In the case of NHS organisations already completing a Serious Incident Investigation the information produced such as a report, chronology, findings and an action plan should be transferred to the IMR document, within the scope of the terms of reference agreed
  • Individual Management Reviews must be signed off by the Chief Officer of each organisation

Multi Agency Chronology

Chronologies are important tools particularly when combined across organisations. This enables a group of organisations to identify gaps in specific areas such as communication, decision making and risk assessment.

Many of the methodologies outlined utilise chronologies within them, however, they can be used in isolation to achieve an overview of a case fairly simply, which can assist in assuring or developing multi-agency working.

In this approach each agency produces a single chronology of involvement, over the period that has been agreed as relevant to the investigation or review. They may also be asked to provide chronologies relating to more than one person of interest in the case.

Where chronologies are used, all relevant agencies will be asked to complete a Chronology of their agency’s involvement, over the period that has been agreed as relevant to the review, this may involve more than one person of interest relating to the case.

They may also be asked to include a chronology of any organisational changes which may have impacted on frontline practice during the same period.

How to Complete a Chronology and What is a Key Event Chronology?

A ‘key event’ is a significant incident that impacts on the adult at risk’s safety and welfare, circumstances or home environment. This will require a professional decision and / or judgement based upon the AARs individual circumstances.

It is crucial that the information recorded in a chronology is relevant and succinct to avoid key events becoming lost in a mass of insignificant and irrelevant detail.

The events or incidents that should be recorded will vary from case to case depending upon the nature of the risks and harm. The following are some examples, but it should be noted that this is not an exhaustive list:

  • Contacts or referrals about the AAR
  • Assessments undertaken – health, social care, safeguarding, occupational health, fire risk, clutter scale, mental capacity etc
  • Strategy Discussions
  • Meetings and/or Multi-Agency Risk Management (MARM) Meetings
  • Safeguarding enquiries and Section 42 investigations
  • Non-accidental injury and significant injury or neglect events
  • Attendance / admittance to hospital
  • Births, deaths, serious illness of significant others
  • House moves; Homelessness
  • Immigration status – No Recourse to Public Funds
  • Input of carers
  • Changes in family composition, including new partners, separations, non-family members moving into family home;
  • Criminal proceedings and outcomes
  • Involvement of Office of the Public Guardian and any Lasting Powers of Attorney
  • Civil proceedings involving the family
  • Change in GP
  • Self-referrals and any referrals to other agencies / teams
  • Police logs detailing relevant incidents at family home or in relation to family members, such as reported incidents of domestic abuse, self-neglect, drunken / anti-social behaviour
  • Attempted suicide or overdose of AAR
  • Events showing capacity of AAR and their family to work in partnership and engage with professionals
  • Frequent presence of unknown adults;
  • Any event in the AARs life deemed to have a significant effect on them, such as separation from main carer leading to poor attachment.

Chronologies will be combined to produce an Integrated Chronology. This will often be colour coded to facilitate an ‘at a glance’ overview of agency involvement. This enables a review in determining whether there appears to be grounds for further investigation or potential for learning through more detailed examination and discussion in a multi-agency workshop.

For more infomation please see our Guidance for completing SAR Chronologies

Reflective Learning Workshop

Reflective Learning Workshops provide a forum for frontline professionals and their line managers to come together in a respectful, positive and supportive environment to consider the circumstances surrounding the case and the reasons why actions were taken. This enables the Lead Reviewer to identify important multi-agency learning.

The Panel will need to ensure it has a full list of appropriate professionals and line managers to invite to the Learning Workshop. This will usually be requested alongside the Chronology and/or Information Report.

To maximise learning all agencies are expected to ensure that appropriate staff attend the workshop. However, it is preferable that only those who have had some form of direct operational involvement with the AAR and their family should attend. They can be supported by their manager or a colleague.

Invitations to Reflective Learning Workshop will be sent to all participants giving plenty of notice. This will be accompanied by a short briefing which explains the purpose of the event and the importance of attending.

The Lead Reviewer will normally facilitate the Reflective Learning Workshop, supported by members of the Panel and/or the ISPS.

The structure of the Workshop will vary depending on the case but is likely to include a discussion of:

  • the information compiled about the AAR and their family in terms of incidents and professional interventions with an opportunity for participants to query the factual accuracy, to add information and to agree changes;
  • the “lived experience of the adult”. This enables participants to view what happened from the AAR’s perspective;
  • the reasons why events and practice happened the way they did, including any organisational and ‘systems’ factors that may have shaped behaviour (such as organisational/team aims or culture, levels of supervision, or the resources available to deliver services);
  • the key themes which have emerged in the case and whether they can be transposed to working with AAR and their families more generally; and
  • any examples of good practice;
  • the learning from the case and actions that should be taken to better safeguard AAR in the future.

Within these discussions it is essential that all actions and decisions (or lack of them) by professionals are viewed within the context of the information available at the time and system in which they were working.

The Lead Reviewer will assist the group to avoid hindsight bias in their consideration of what took place.

Where an individual with important information to contribute to the review is unable to participate, arrangements may be made to facilitate a conversation with the Lead Reviewer to enable them to contribute to the learning.

Peer Review Approach

Peer Led Reviews (PLR) provide an opportunity for an objective overview of practice, with potential for alternative approaches and/or recommendations for improved practice.

Although peer reviews tend to be wholly undertaken by one external team, there can be flexibility within this option regarding the balance of peer team to maximise identified expertise and increase viability. They can be developed as part of regional reciprocal arrangements which identify and utilise skills and enhance reflective practice. Such reviews can be cost effective and spread learning. Likewise, there can be flexibility regarding the exact methodology to be adopted in order to achieve the desired outcomes of the review.

Root Cause Analysis

Root Cause Analysis (RCA) is a technique which can be used to uncover the underlying causes of an incident. It looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened. It is designed to identify the sequence of events working back from the incident itself and identifies a range of factors which contributed to the incident.

This allows the real causes and contributory factors to be identified so that the relevant organisations can learn and put remedial actions in place.

Significant Event Analysis

Significant Event Analysis (SEA) brings together managers and/or practitioners to consider significant events within a case and analyse what went well and what could have been done differently. Its focus is on learning which can lead to future improvements and it results in an action plan with recommendations for learning and development. Staff are brought together in a facilitated team approach.

This methodology has been used for many years in General Practice and in other areas of the NHS. The adult at risk is not involved in SEAs, however, the findings may instigate further review or investigation which should involve them.