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What is a Safeguarding Adult Review (SAR)?

According to Part One Section 44 of the Care Act 2014 Safeguarding Adult Boards (i.e. Cambridgeshire and Peterborough Safeguarding Adult Partnership Board) must undertake a Safeguarding Adult Review (SAR) when:

  1. An adult in its area with care and support needs (i.e. an adult at risk) has died as a result of abuse or neglect whether this was known or suspected before the adult died and there is concern that partner agencies could have worked more effectively to protect the adult.
  2. An adult in its area with care and support needs (i.e. an adult at risk) has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect and there is concern that partner agencies could have worked more effectively to protect the adult.

The purpose of a Safeguarding Adults Review is to learn the lessons about how professionals and organisations work together, and to consider how the learning can be used to improve practice for others in the future.

(Adapted and Taken from Care Act 2014 and Cambridgeshire and Peterborough Safeguarding Adult Partnership Board Website)

The SAR Audit

An initial Thematic Report (January 2020) looked at all SARs undertaken from 2011 – 2018 across Peterborough and Cambridgeshire. A request from the SAR group was for a smaller audit of SARs to be undertaken from after the Care Act 2014’s implementation 2015 until 2019. This was due to the changes that were brought in by the Care Act 2014.

The audit was undertaken with a view to ascertain:

  • good practice areas mentioned within the SARS
  • areas of professional practice identified for improvement within the SARs
  • how the recommendations and actions arising from the SARs had contributed to improving practice

A thematic review was undertaken, whereby each report and the action plans were read in turn.


 In total three Safeguarding Adult Reviews were undertaken across the county between the period 2015 to 2019. This is a very small sample, consequently caution should be applied when considering the findings below.

Professional Practice

 It is important to note that in all of these reviews the report authors stated that despite what professionals did or did not do, the outcome for the adult at risk may have been the same. For each of these adults at risk they had a number of life impacting variables such as their older ages and existing complex health conditions

Good Practice

Within three of the reports there was a small section, ranging from a paragraph to a page that focused on ‘good practice’. Even though in some of the reports the terms of reference included the requirement for good practice to be highlighted there was very little mention of it. This does not mean that there was no good practice evidenced, but it may not have been included within the report.

Bar Chart to show pictorially the ‘Good Practice’ professional themes in reviews for Cambridgeshire and Peterborough

The top three themes of good practice found within 50% of the reports were: multi-agency working, professionals being persistent with service users and offering supportive practice.

There is currently no research available that focuses solely on the positive practice themes found within Safeguarding Adult Reviews

Professional Practice Areas to Improve On

In every review within this sample, it was noted that there was a lack of recording and completing full assessments by professionals. In terms of recording, practitioners did not record events or give detailed enough accounts. In relation to assessments professionals, did not complete them, made poor assessments/risk assessments, did not reassess and failed to complete them in time to support the adult at risk.

The phrase ‘missed opportunities’ was also recorded in 100 % of these cases. Missed opportunities are individual to each case and were often situations that the report authors felt could and should have been acted upon by professionals.

In 75% of this sample of reviews it was ascertained that practitioners; failed to share information and to make safeguarding referrals, did not follow policies and procedures nor work together to safeguard the adult at risk.

The professional theme of practitioners ascertaining the lived experience of the adult, finding out what life is like for the adult at risk featured within 50% of SARs. It is important to note that it is ‘good practice’ that professionals actively seek the lived experience of the adult at risk in order to inform their assessments, planning and the support that can be offered to safeguard them. 

Bar Chart to show pictorially the professional themes in reviews for both Cambridgeshire and Peterborough

These recurring professional themes are similar to findings within recent research as referenced by Suzy Braye and Michael Preston-Shoot (2017), who looked at 27 SARs from 2015 to 2017 across the London borough and Hull Safeguarding Adult Board (2014) who examined the recommendations of 74 SARs undertaken by local authorities from 2003 to 2013.

What has changed since the SARs?

Looking at all of the completed recommendations in the SARS and the corresponding action plans as a whole, below illustrates how practice has changed and improved since the commission of the safeguarding adult reviews within this sample.

Task and Finish Groups

A number of different task and finish groups have been set up to focus on some of the findings within the SARs and these included groups on; Discharge and Planning and Pressure Ulcers.


The Multi-Agency Risk Management Tool (MARM) was developed and launched within workshops during 2019. This tool supports multi-agency meetings for complex cases and continued risk assessment to support the adult at risk.

As a result of the SARs and number of multi-agency policies and procedures have either been reviewed or developed and are situated on the safeguarding adult partnership board’s website.

Single Agency

Within the action plans were a number of actions undertaken by single agencies as a result of the SAR and recommendations. These were varied and included areas such as developing leaflets, sharing discharge plans with patient, carers and families and implementing daily meetings

Multi-Agency Training

Since the reviews, the safeguarding partnership board has integrated a multi-agency training programme that offers both children and adult safeguarding training to statutory and voluntary agencies.

Workshops, face to face and now virtually, have been cascaded since 2019 where the lessons learned from national and local SARs are highlighted and discussed.

Workshops on the ‘lived experience of the adult’ took place during 2019 which were well attended and received. Practitioner guidance on the lived experience of the adult was launched during August 2019 within the latest virtual learning lessons workshops.

For two of the SARs within this sample practitioner briefings were written to share with professionals the themes within the SAR and how to improve safeguarding practice. The briefings are used to support single and multi-agency training.

A number of training slides, resources and SWAYs are available for practitioners on the board’s website.

Further Information

Adult Safeguarding Partnership Board Website –

Multi-Agency Safeguarding Training –

Safeguarding Adult Reviews –

Leaflets, Resource Pack –

Multi-Agency Policies and Procedures –

MARM Guidance –

Lived Experience of the Adult Guidance –


Braye, S., and Preston-Shoot, M., 2017 .Learning from SARs: a report for the London Safeguarding Adults Board: London

Care Act 2014. London: HMSO

Hull Safeguarding Adult Board., 2014: A decade of serious case reviews: Hull: Hull Safeguarding Adult Board

September 2020

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