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Safeguarding Adult Reviews

The Herefordshire Safeguarding Adults Board has a legal duty to undertake Safeguarding Adult Reviews (SAR) of cases 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 them. The criteria for such reviews is set out in the Care Act 2014.

Think SAR

Safeguarding Adult Reviews are held so that lessons can be learned from the case and those lessons are applied to future cases to prevent similar harm occurring again.

If as a professional you have a case where you are concerned that agencies have not worked together effectively, discuss your concerns with your line manager and/or safeguarding lead who can advise whether the case should be referred to Herefordshire Safeguarding Adults Board Joint Case Review sub group for consideration. Members of the public can also refer a case for consideration, contact an appropriate professional to discuss your concerns.

Read our guidance on whether a SAR is needed –  SAR Flowchart

Read the HSAB Operating Guidance for more information about SAR procedures – HSAB SAR Operating Guidance 

Referral form

To make a referral to the Joint Case Review sub group complete this form

Recently published SARs

Safeguarding Adults Review “Dorothy” was published in January 2023 by the Worcestershire Safeguarding Adults Board, which involved a lady who was originally from Herefordshire. Read the Learning Briefing here – Dorothy SAR Learning Briefing 

A thematic review into premature deaths of adults was published in March 2022 – see HSAB Thematic Review – Premature Deaths

How a SAR should be undertaken

Statutory guidance (Care Act, para. 14.135-14.144) outlines principles that should underpin all SARs, how the SAR should be undertaken (including the skills and experience needed of those undertaking a SAR), what the SAR should aim to achieve and suggested reasonable timescales. When setting up a SAR the Safeguarding Adults Board should consider how the process can dovetail with any other relevant investigations that are running parallel, including Child Safeguarding Practice Reviews and Domestic Homicide Reviews.

Statutory Duty

  • Where the Safeguarding Adults Board decides not to implement the finding of a review, it must state the reason for that decision in the Annual Report (Care Act, Schedule 2, 4(1)).
  • Each Safeguarding Adults Board member must cooperate in & contribute to the carrying out of a review with a view to identifying lessons to be learnt and applying those lessons in future cases (Care Act 44(5))

Herefordshire follows the West Midlands regional guidance on completing Safeguarding Adult Reviews. See the guidance: West Midlands Regional Safeguarding Adults Reviews Guidance 

See Escalation Protocol for Issues from Safeguarding Adult Reviews for the nationally agreed escalation protocol to escalate issues that arise from local SARs, which require a national response.

Findings from Safeguarding Adult Reviews (SARs)

SAR reports should provide a sound analysis of what happened, why and what action needs to be taken. The report should be written in plain English and contain findings of practical value to organisations & professionals. Findings from any SAR should be included in the Safeguarding Adults Board Annual Report, including what actions have been taken (or intend to be taken) in relation to the findings.

Copies of Herefordshire’s recently completed reviews can be found below:

A national review of all SARS undertaken between April 2017 and March 2019 has been carried out, the findings have been considered by the HSAB and are included in their action plan.  The full report is here:  National SAR Analysis

The HSAB will publish any completed reports and accompanying learning on this website, unless doing so causes harm or risk to any family involved. The report will also be submitted to the national SAR repository.

If it is not deemed appropriate to publish a report locally, the learning will be published and the HSAB will seek to publish it anonymously on the national SAR repository.

The HSAB also follows its Media Protocol when publishing a Safeguarding Adults Review. See HSAB Media Protocol

A library that holds all SARs published nationally is available.  This repository allows practitioners to search all SARs that have been published nationally. The National Network has provided guidance on how to use the library and the search terms available. You can access the national SAR library here.