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.
National Safeguarding Adults Board Manager Network guidance on the interface between safeguarding adult reviews and coronial processes
The National Safeguarding Adults Board Manager Network has developed this guidance, which is attached to this page.
The guidance aims to help identify how, when, and why joint working might be requested and/or be required and helpful. The intention is to minimise delays in respective statutory processes, as well as keeping relevant parties informed.
This briefing contains an overview of legislative guidelines, good practice guidance, helpful tools and templates, and examples of local protocols, and has been developed to inform local working arrangements and support a joined-up approach.
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 the SAR22A learning brief for ‘William’
“The Derbyshire Safeguarding Adults Board (DSAB) commissioned a Safeguarding Adult Review (SAR) in 2022 in accordance with the Care Act 2014 in relation to the sad death of an adult who we refer to as William in order to protect his identity. William died following a fall at his home. Prior to his death, concerns had been raised about the risk of harm posed to William, due to him living in circumstances of self neglect.
The SAR is now complete, and a learning brief and learning on one page (LOOP) have been published on the DSAB website to provide an overview of the circumstances, findings, good practice, and recommendations.
I ask all practitioners and managers from across the partnership to take the time to read and reflect on the information within the learning brief and discuss at your team meetings, supervisions, within training and use as part of your own professional development.
Three recommendations were made in this SAR and work is well underway to ensure that the learning makes a difference to the support we provide to adults living in similar circumstances to William in the future. This includes the recent launch of a brand new self-neglect toolkit for front line staff and managers across all agencies to support them to achieve the best possible outcomes when working with adults who are at risk of harm due to self neglect. The Board will continue to monitor progress and seek assurance that the learning from this SAR is fully implemented.
"I would like to thank all those who were involved in the SAR process, especially the Independent Author, Sylvia Manson, the SAR panel and also William’s friend, who provided a valuable insight into William’s earlier life and circumstances.”
Andy Searle, Independent Chair, Derbyshire Safeguarding Adults Board.