Safeguarding Adults Reviews (SARs)
What is a Safeguarding Adult Review?
A Safeguarding Adults Review (SAR) is a process for all partner agencies to identify the lessons that can be learned from particularly complex or serious safeguarding adult cases, where an adult in vulnerable circumstances has died or been seriously injured, and abuse or neglect has been suspected. As a result of a detailed review, recommendations are made to change or improve practice and services.
The aim of the process is to learn lessons and make improvements, not to apportion blame to individual people or organisations.
A SAR is about promoting effective learning and improvement to prevent future deaths or serious harm occurring again.
It relies on a spirit of openness to learning about what went well, as well as what could be improved. The process is based on national guidelines and has been agreed by all agencies who are members of the Norfolk Safeguarding Adults Board.
Further information can be found in the Care and Support Statutory Guidance, Chapter 14, paragraphs 14.133 and 14.134.
Criteria for a SAR
The Norfolk Safeguarding Adults Board must arrange a Safeguarding Adult Review (SAR) when:
An adult with care and support needs (whether or not those needs are met by the local authority) in the SAB area has died as a result of abuse or neglect, whether known or suspected and there is concern that partner agencies could have worked together more effectively to protect the adult. (section 44(2))
Or
An adult with care and support needs (whether or not those needs are met by the local authority) in the SAB’s area has not died, but the SAB knows or suspects the adult has experienced serious abuse or neglect and there is concern the partner agencies could have worked together more effectively to protect the individual. (section 44(3))
Or
The SAB can arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs). (section 44(4))
* In the context of SARs, something can be considered serious abuse or neglect where, for example the individual would have been likely to have died but for an intervention, or has suffered permanent harm or had reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect.
More information (including SAR Policy and SAR1 Referral Form)
Additional Source: Care Act (2014) Guidance - 14.162 and 14.163
SAR learning
We have a page for additional learning from SARs guidance too:
Norfolk Safeguarding Adults Board: SARs published between January 2024 to June 2025
| SAR | Published | Themes |
| SAR X | March 2025 |
proactive planning and mapping of needs multi-agency collaboration early intervention and referral integrated service models clear roles/communication information sharing policy and guidance clarification |
| SAR Eric | February 2025 |
suitability of service voice of Eric assessment/management of risks threats of suicide and response to these problematic alcohol abuse non engagement analysis of capacity at each decision making point |
| SAR S | July 2024 |
mental ill health loneliness cuckooing and exploitation drug & alcohol use role of housing when safeguarding concerns are raised use of Multi-Disciplinary Team (MDT) meetings the assessment of a person’s mental capacity |
| SAR R | June 2024 |
physical health needs hospital discharge equipment provision pressure ulcer care escalation pathways complex bed-based care interagency communication mental capacity assessment |
| SAR P | February 2024 |
physical disability mental ill health drug and alcohol use community alarm |
See below for links to the individual SARs
