Learning and improvement

Safeguarding Adult Review

A Safeguarding Adult Review (SAR) (formerly a Serious Case Review) establishes whether there are lessons to be learnt from the circumstances of a specific case and is a statutory requirement under the Care Act 2014.

It involves a multi-agency review to determine what individuals and agencies could have done differently that may have prevented harm or a death from taking place. The purpose of a SAR is not to apportion blame, it is to promote effective learning and improvement to prevent future deaths or serious harm occurring again.

A SAR is commissioned when the WSAB is alerted to a situation where:

  • There is reasonable cause for concern about how WSAB members or other agencies providing services worked together to safeguard an adult
  • The adult has died and WSAB 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)
  • The adult is still alive, and WSAB knows or suspects that the adult has experienced serious abuse or neglect.

To find out more see the Care and Support Statutory Guidance (external link), Chapter 14, paragraphs 14.133 and 14.134.

Serious Adult Reviews

SAR One Review (completed September 2016): Male in his 30’s with a learning disability who suffered a sexual assault by a minor. A decision has been taken not to publish this report, as the carer’s for the victim are all alive and being actively worked with, and despite attempts at anonymity, details within the report would be too recognisable.

SAR Two Review (completed August 2017): Adult male leading chaotic / complex lifestyle assaulted by associates (some evidence of financial abuse) and later died of injuries (offenders were later sentenced to prison). Review focused on the services response to complex clients from an early intervention perspective.

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