5.7 Safeguarding Adult Reviews (SARs)

1. Introduction

The Care Act 2014 states that Safeguarding Adult Boards (SABs) must arrange a Safeguarding Adults Review (SAR) when:

• an adult in its area with care and support needs 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.

SABs must also arrange a SAR if an adult with care and support needs, 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 was likely to have died but for an intervention, or suffered permanent harm or has reduced mental capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect.

SABs may arrange for a SAR in any other situations involving an adult in its area with care and support needs, whether or not they are being met by the local authority. The SAB may also commission a SAR in other circumstances where it feels it would be useful, including learning from ‘near misses’ and situations where the arrangements worked especially well. The SAB decides when a SAR is necessary, arranges for its conduct and if it so decides, implements the findings.

2. Criteria

The criteria are met when:

• an adult dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in their death; or
• an adult has sustained a potentially life threatening injury through abuse, neglect, serious sexual abuse or sustained serious and permanent impairment of health or development through abuse or neglect; and one of the following:
• where procedures may have failed and the case gives rise to serious concerns about the way in which local professionals and / or services worked together to safeguard adults;
• serious or apparently systematic abuse that takes place in an institution or when multiple abusers are involved. Such reviews are likely to be more complex, on a larger scale and may require more time;
• where circumstances give rise to serious public concern or adverse media interest in relation to an adult.

There is an expectation that individuals, agencies and organisations, cooperate with the review.. However,t the Act also gives the Safeguarding Adults Board (SAB) the power to require information from relevant parties. The SAB may also commission a SAR in other circumstances where it feels this would be useful, including learning from ‘near misses’ and situations where the arrangements worked especially well. The SAB will decide when a SAR is necessary, arrange for its conduct and if it so decides, implement the findings.

3. Criminal Investigations and Police Involvement

Where there is an ongoing criminal investigation or criminal proceedings, the SAB will need to consider, in consultation with the police, whether continuing with the SAR might prejudice their outcome and whether the completion of the SAR should be postponed until after the criminal investigation or proceedings have been completed.

4. Outside of a SAR Remit

Where the Safeguarding Adult Board agrees that a situation does not meet the criteria but agencies will benefit from a review of actions other methodologies may be considered. These include:

• Serious Incident Review: organisations should use their own serious incident procedures if this is deemed suitable and special consideration should be given to the involvement of relevant partner organisation;.
• Management review: a review by an individual organisation in relation to their understanding and management of a particular safeguarding issue;
• Reflective Practice Session: The original participants in the case may review identified aspects of the case as part a reflective practice session chaired by the safeguarding lead or other relevant person, including an independent facilitator;
• Learning Together SCIE: which is a collaborative scrutiny approach to a case review.

5. Principles

SARs will reflect the six adult safeguarding principles and be conducted within a framework of openness and transparency (see Context, Principles and Values chapter, Principles of Adult Safeguarding).

6. Purpose

The purpose of all SARs is to keep the focus on learning. The final SAR report and those responsible for disseminating the learning from it, should ensure that the recommendations can be translated into practice, not just for those involved but to a wider audience to support prevention strategies and influence strategic plans.

It is not for a SAR to investigate how a death or serious incident happened. Neither is it the responsibility of the SAR to apportion blame. Such matters will be dealt with by the Coroner’s or criminal courts, or other bodies.

7. The Adult

In non-fatal cases, the views of the adult should be central to the decision making process about the type of SAR to undertake. Communication should be established at the earliest opportunity and advocacy provided to support the adult. Information should be given about how the SAR will be conducted and how they can be involved or, in the event that the adult has deceased, how nominated people can be involved.

Where there is a police led investigation, close contact with any appointed police Family Liaison Officer should be made. Communication should be clear and consistent between all designated supporters including independent advocates. See Section 3, Criminal Investigations and Police Involvement above in relation to cases where there is an ongoing criminal investigation or criminal proceedings.

8. Person alleged to have caused harm

The emphasis on learning should include the person alleged to have caused abuse or neglect so they can adjust their behaviour, act differently and reflect upon the impact that they might have had on others. This may involve liaison with other professionals, working with, or trained to work with people who abuse.

9. Advocacy

The local authority must arrange, where necessary, for an independent advocate to support and represent an adult who is the subject of a SAR. Where the adult is deceased, it is good practice to provide advocacy to family / friends.

10. Carers

The desired outcome, especially where a family is bereaved, needs to be approached with sensitivity. Consultation and involvement needs to be balanced with the overall wellbeing of the individuals involved. Throughout the process due diligence, compassion and appropriate support should be provided and the relevant local authority community team should be available to provide this or an alternative arranged if more appropriate.

11. Staff

All professionals should be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Where an adult has died, professionals working with that adult should have the opportunity to discuss their feelings in a safe environment and offered counselling or other therapeutic support. Professional supervision may not be the most helpful means of exploring any fears or anxieties or coping mechanisms to enable professionals to take an objective view and learn from the SAR. There will be occasions when allegations are made that staff have been guilty of abuse against adults.

If the staff member is subject to a criminal investigation, consideration will need to be given to the timing of any SAR (see Section 3, Criminal Investigations and Police Involvement).

If the staff member is subject to a disciplinary enquiry, it is likely that the SAR will work alongside the disciplinary enquiry.

12. Who should undertake a SAR?

The individual commissioned to undertake the SAR should be independent of the organisations involved. They should have the appropriate core skills including:

• strong leadership and ability to motivate others;
• expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
• collaborative problem solving experience and knowledge of participative approaches;
• ability to find and evaluate best practice;
• good analytic skills and ability to manage quantitative and qualitative data;
• knowledge of safeguarding adults;
• ability to write for a wide audience and
• an understanding of the complexity of the health and social care system .

13. Requests

Any individual, agency or professional can request a SAR. This should be made in writing to the Chair of the Safeguarding Adults Board using the agreed referral form contained in Referral Form for a Safeguarding Adult Review. The following information should be included:

• what happened – with dates if known;
• the views of the adult / family / carer;
• where the incident / concerns took place;
• who was involved and their organisation and
• why the request is being made.

The SAR subgroup will consider the request against the criteria in the Care Act in order to ensure the SAR process is consistently applied. Agreement to carry out a SAR should be recorded on relevant systems across the statutory agencies.

14. Commissioning a SAR

The Safeguarding Adults Board is the only body authorised to commission a SAR and decide when a SAR is necessary; arrange for its conduct and if it so decides, to oversee implementation of the findings.

The Safeguarding Adults Board will convene a subgroup to act on its behalf to receive and manage requests, and have delegated commissioning responsibilities. In commissioning a SAR the agreed protocol will be followed (see .South Tyneside Safeguarding Adult Review (SAR) Protocol). 

Whatever arrangements are in place, where there is agreement for a SAR, a SAR chair will be identified to co-ordinate arrangements.

14.1 SAR options

A number of options may be considered by the Safeguarding Adults Board or delegated subgroup. The approach used for the SAR be the most appropriate and proportionate model for the situation. No one model will be applicable for all cases. The focus must be on what needs to happen to achieve understanding, take remedial action and, very often, provide answers for families and friends of adults who have died or been seriously abused or neglected. Every effort should be made while the SAR is in progress to capture points from the case about improvements needed and to take corrective action.

When commissioning a SAR the following points will be agreed:

• scope of the terms of reference;
• knowledge, skills and experience of the reviewer;
• timescales for completion;
• who will secure any legal advice required;
• how the interface between the SAR and any other investigations or reviews will be managed;
• a communication strategy, including clarification about what information can be shared, when and where (conditions);
• a media strategy;
• what the arrangements for administrative and professional support are and
• how it will be paid for.

15. Links with other Reviews and Investigations

For victims of domestic homicide, there is separate statutory guidance in respect of children, which provides for a  Child Safeguarding Practice Review (see also Working Together to Safeguarding Children, gov.uk) and in respect of persons aged 16 or over, which provides for a  Domestic Homicide Review (DHR) (see Multi-agency Statutory Guidance for the Conduct of Domestic Homicide Reviews, Home Office).

These two sets of statutory guidance overlap where the victims are aged between 16 and 18.  When commissioning a SAR there will be consideration of how it how will dovetail with other statutory reviews and any other investigations.

The guidance for DHR states consideration should be given to how the Child Safeguarding Practice Reviews and DHRs can be managed in parallel in the most effective way, so that organisations/professionals can learn from the case. Different types of reviews will have their own specific areas of investigation and these should be respected. Where intelligence can be shared across reviews, there should be no organisational barriers to information sharing. It is also helpful to consider if some aspects of the reviews can be commissioned jointly to reduce duplication.

16. Coroners

Any SAR may need to take account of a Coroners’ inquiry, including disclosure issues, to ensure that relevant information can be shared without incurring significant delay. Coroners are independent judicial officer holders who are responsible for investigating violent, unnatural deaths or deaths of unknown cause, and deaths in custody, or otherwise in state detention, which are reported to them. The Coroner may have specific questions arising from the death of an adult, these include:

• where there is an obvious and serious failing by one or more organisations;
• where there are no obvious failings, but the actions taken by organisations require further exploration/explanation;
• where a death has occurred and there are concerns for others in the same household or other setting (such as a care home);
• deaths that fall outside the requirement to hold an inquest but follow-up enquiries/actions are identified by the Coroner or their officers.

Where the Coroner identifies issues such as these, the SAB will consider whether a SAR is required.

17. Findings from SARs

The findings and outcomes of any SAR will be captured within the Safeguarding Adults Board Annual Report and online (see Local Safeguarding Adult Reviews, South Tyneside Council website)

18. Timetable

The timescale from the decision to conduct a SAR to completion is six months. In the event that the SAR is likely to take longer for example, because of potential prejudice to related court proceedings, the adult/advocate and others will be advised in writing the reasons for the delay and kept updated on progress.