Last updated: 27.01.20

What is a Safeguarding Adult Review?

When it comes to safeguarding adults, reviews are carried out throughout the UK in order to understand and analyse cases where abuse or neglect is known or suspected. Each region has its own name for its reviews – Safeguarding Adults Reviews are relevant to England. Please select another region to find out about its  type of inquiry: Wales, Scotland and Northern Ireland.

Context for Safeguarding Adults Reviews (SARs)

Safeguarding Adults Reviews (SARs) were introduced in section 44 of the Care Act 2014 and are conducted by Safeguarding Adults Boards (SABs). Previously these reviews were called Serious Case Reviews (SCRs).

SAR’s align to the six principles of adult safeguarding outlined in the Care Act 2014:

Empowerment: people are supported and encouraged to make their own decisions.

Prevention: to take action before harm occurs.

Proportionality: using the least intrusive responses that are appropriate to the risk presented.

Protection: protect adults who are at risk of harm.

Partnership: work closely together with organisations and professional to prevent, detect and report neglect and abuse.

Accountability: accountability and transparency in safeguarding.

The Purpose of a SAR
The overall purpose of a SAR is to learn and improve. They are carried out to:

  • Understand why an adult came to harm
  • Identify contributory factors to the harm of an adult
  • Agree actions to prevent future deaths or serious harm occurring again.
  • Look at examples of good practice and agree how this can be used to improve safeguarding practice.

What a Safeguarding Adults Review is not: Public inquiries and SARs

SARs are not to be confused with public inquiries.

Public inquiries are set up by government under the Inquiries Act 2005 and aim to investigate events which have, or could cause public concern. They are led by one person (or a panel) who conducts an investigation into what happened and recommendations are made to reduce the risk of harm occurring again. 

Public inquiry example: Mid Staffordshire NHS Foundation Trust

Between January 2005 and March 2009 at Staffordshire hospital between 400-1,200 patients died because of poor and unsafe care. Death rates were unusually high, forming an issue of public concern.

Robert Francis, a barrister specialising in NHS and medical negligence was commissioned by Andrew Lansley, the Health Secretary in the Department for Health in 2010 to investigate what happened. 


 In 2013 the Francis Report was published reporting a number of failings. Patients were neglected, food and drink was left out of reach of patients, medication was delayed, there were administration issues, staffing shortages, poor hygiene and a culture of bullying. Effectively, the NHS was shown to be negligent in the care of patients.

Changes to practice and regulation (‘the Francis effect’)

Increased staffing numbers in hospitals to improve and support those falling below the expected standard.  Nurses now have to work in frontline roles as part of their training. Patients are frequently encouraged to ask for feedback on their care and treatment. The Care Quality Commission introduced Expert by Experience (ExE) roles, allowing patient and public representatives to take part in inspections to represent the views of people using services.

Function and role of Safeguarding Adults Boards (SABs)

Every local authority across the country must form a Safeguarding Adults Board (SAB). A SAB consists of a minimum of three core members: the local authority, clinical commissioning groups (CCGs) and the police.

The function of a SAB is to help protect adults who meet the following three conditions:

  • Have care and support needs (whether or not the local authority is meeting any of those needs).
  • Is experiencing, or is at risk of abuse, or neglect.
  • As a result of those needs is unable to protect themselves against the abuse and neglect, or the risk of it.

As part of these roles, they may, at times, be required to conduct a SAR.

When a SAB is required to conduct a SAR

There are four circumstances when The Care Act 2014 requires SABs to complete a SAR:

  • There is reasonable cause for concern about how the SAB, its members and other persons involved in the SAB worked together to safeguard an adult. Where there are concerns that organisations did not work effectively together to safeguard an adult and the abuse or neglect was avoidable a SAR is required.


  • An adult has died and there is a suspicion the death occurred from abuse and neglect, irrespective of whether the SAB was aware of the abuse and neglect or not.


  • The adult is still alive, but has experienced serious abuse or neglect.


  • Where good practice is identified, so lessons can be learned and applied to improve the effectiveness of safeguarding practice.

Serious abuse and neglect

To help provide some context, serious abuse and neglect is understood to have occurred when an adult:

  • May have died if it wasn’t for an intervention to stop the continuation of the abuse
  • Has suffered permanent harm as a consequence of the abuse or neglect
  • Has reduced capacity is a consequence of the abuse or neglect
  • Experiences a reduced quality of life, because of the physical and psychological impact of the abuse and neglect

The SABs role in SARs

All members of the SAB are expected to cooperate and contribute to SARs, identifying lessons learned and applying them to future safeguarding practice.

Reviews should be completed within a reasonable time period of an adult dying or experiencing serious harm.  Any review that is required must be conducted within a six-month time period.

Each year SABs must publish an annual report, detailing the findings of SARs, ongoing reviews and actions that have been taken following these reviews. If actions have not been taken, the SAB must provide reasons for this.

SARs should be published. This supports transparency, though confidentiality must be applied in line with the Data Protection Act 2018.  There is no explicit duty for SABs to publish, some choose not to because they feel organisations and individuals involved in SARs will be more willing to disclose information.

Previous Safeguarding Adults Reviews and Learning

There are a number of Serious Case Reviews (SCR), prior to SARs under the Care Act 2014, that demonstrate the way in which SABs have used these as opportunities to improve learning.  

Lessons learned from these high-profile SCRs have contributed to current safeguarding practice outlined in the Care Act 2014.

The following SCRs were high profile, receiving national attention and can be considered key cornerstones to the improvements and development of adult safeguarding practice in England. Select each name for more information.

Winterbourne View

Orchid View

Steven Hoskin

Serious Adult Reviews: Online Access

Although not all safeguarding adult reviews reach a national audience, each and every review provides crucial opportunities for Safeguarding Adults Boards (SAB) to improve their safeguarding practice. This means, they are in a better position to meet the requirements for safeguarding set out in the Care Act 2014 and protect many adults who may be at risk of abuse.

You can look at the current SAR’s in your local area, by going ongoing and accessing the Safeguarding Adults Review area of your local authority’s website. This will assist you in your learning and continued development as a frontline work, encouraging you to reflect and become competent in your own safeguarding practice.