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.