Safeguarding Adult Review

TSAB must arrange a Safeguarding Adult Review (SAR) when an adult in its area 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 the adult.

TSAB must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. 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 has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect.

TSAB may also arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

The TSAB should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. 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. Safeguarding adult reviews may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases.

TSAB shall apply the following principles to all reviews:

  • there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the wellbeing and empowerment of adults, identifying opportunities to draw on what works and promote good practice
  • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined
  • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed
  • professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith
  • families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively

Safeguarding Adults Board review of Western Rise Care Home

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