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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 safeguarding adult board’s (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.

Or/and

  • 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.

Or

  • The SAB has discretion to undertake a SAR in other situations where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults, and can include exploring examples of good practice.

Or

  • The SAB can also consider conducting a SAR into any incident(s) or case(s) involving adults(s) at risk of abuse or neglect where it is believed to be in the public interest to conduct such a review.

* 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 14.63

SAR learning

We have a page for additional learning from SARs guidance too:

Additional learning through SAR process