Safeguarding Adults Reviews

The Care Act 2014 sets out that SABs have a statutory duty to undertake a Safeguarding Adults Review (SAR) when:

an adult has died (including death by suicide), and abuse or neglect is known or suspected to be a factor in their death;

an adult has experienced serious abuse or neglect which has resulted in: permanent harm, reduced capacity or quality of life (whether because of physical or psychological effects), or the individual would have been likely to have died but for an intervention;

and

there is concern that partner agencies could have worked more effectively to protect the adult.

Purpose of a SAR

The purpose of a SAR is not to to apportion blame, it is to:

establish whether there are any lessons to be learnt from the circumstances of the case, about the way in which local professionals and agencies work together to safeguard adults,
review the effectiveness of procedures,
inform and improve local inter-agency practice,
improve practice by acting on learning, and,
highlight good practice.

The Sussex SAR Protocol adopted by Brighton & Hove, East Sussex and West Sussex SABS aims to ensure there is a consistent approach to the process and practice of SARs across Sussex that follows both statutory guidance and local policies.

Any agency or professional can make a referral for a SAR where the criteria are met, using the SAR Referral Form .

Our Published SARs

Adult A SAR – published October 2017

This SAR evaluated multi-agency responses to the death of a man (Adult A) aged 64, from Kent, who was living in a nursing home in East Sussex, commissioned by NHS West Kent Clinical Commissioning Group. Adult A died as a result of sepsis, infection of his legs, diabetes and cirrhosis. He was subject to a Deprivation of Liberty as he was deemed to lack capacity to decide where to live. There were concerns of self-neglect as he often refused care and treatment. The review demonstrates how crucial it is for all agencies to work together, sharing expertise to plan and deliver the best possible services to meet people’s care and support needs.

The Adult A SAR – published October 2017 documents include the SAR overview report, action plan and learning briefing.

Adult B SAR – published February 2020

This SAR was initiated in response to the death of a 94 year-old woman in September 2017, referred to as Adult B. The woman died in hospital of natural causes but, when admitted, was found to have 26 unexplained injuries including a fractured nose and jaw, as well as old and new bruising to her face, arms and legs. She was diagnosed with sepsis and pneumonia shortly after her arrival in hospital and she died eight days later. The review evaluated multi-agency responses and the support professionals involved in the case had provided. This case highlighted that professionals can be too inclined to assess the needs and vulnerabilities of adults at face value and that systems do not always allow them to understand the full historical and current context. When this is coupled with a lack of curiosity, and a lack of confidence to challenge family members, it can leave vulnerable people at risk.

The Adult B SAR – published February 2020 documents include the SAR overview report, action plan and learning briefing.