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Safeguarding Adults Reviews

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

Man and woman sitting on curban adult has died, and the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died);


an adult has experienced serious abuse or neglect which has resulted in permanent harm, reduced capacity, or quality of life (whether or not it knew because of physical or psychological effects), or the individual would have been likely to have died but for an intervention;


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:

  1. 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,
  2. review the effectiveness of procedures,
  3. inform and improve local inter-agency practice,
  4. improve practice by acting on learning, and,
  5. 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.

A Sussex SAR Referral Learning Briefing has been produced to support understanding of the SAR criteria and the key considerations when making a referral.

A second national analysis of Safeguarding Adult Reviews (SARs) in England was funded by Partners in Care and Health, supported by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS). Its purpose was to identify priorities for sector-led improvement as a result of learning from SARs completed between 2019 and 2023, a period of time that included the Covid-19 pandemic:

The National SAR library is a database of Safeguarding Adults reviews published by SABs after 1st April 2019. The library is designed to bring together, build on and add value to relevant SAR activity that SABs have undertaken.

There are a number of similar themes identified in Safeguarding Adult Reviews that are undertaken. The three Sussex Safeguarding Adult Boards have worked together to produce a 12 minute podcast that identifies four shared themes identified in reviews undertaken across Sussex and some of the actions that have been undertaken in response. These four themes are; Mental Capacity, Making Safeguarding Personal, Application of Safeguarding processes, and Multi-agency information sharing and communication.

Here is the podcast script to accompany the podcast

Our Published SARs

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 documents include the Overview Report, Action Plan and Learning Briefing.

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 documents include the Adult B Overview Report , Action Plan and SAR Learning Briefing

The SAB commissioned this SAR to understand the circumstances leading up to the death of Adult C in December 2017 and to support the identification of strengths and weaknesses in how agencies worked singly and together.

Adult C experienced significant levels of domestic violence and coercive control, which were particularly severe during the last 12 months of her life, the period which this review focused on. Adult C had multiple complex needs as a result of drug and alcohol dependency, fluctuating mental health (including patterns of self-harm and periods of poor mental health) and homelessness. Her substance misuse led to involvement from Children’s Services and alternative care arrangements for her two children being sought. Adult C was involved in criminal behaviour at times to fund her substance misuse.

The documents include the Overview Report, Adult C Learning Briefing , completed Action Plan and Board Response which contains a statement from Adult C’s family.


Anna was 85 when she died in hospital of natural causes, but her condition on admission had raised concerns because it was noted that Anna had multiple bruises and skin tears over several parts of her body. Previously, safeguarding referrals were raised between December 2016 and 2019, when Anna had been in residential care, but had later returned to live with her daughter – five months before Anna’s death.

East Sussex Safeguarding Adults Board (ESSAB) commissioned a Safeguarding Adult Review (SAR) to understand if lessons could be learnt by organisations who supported Anna, particularly in how the way agencies worked together, to evaluate and understand coercion and control, and protect potential victims of domestic abuse.

It was felt that the circumstances relating to Anna’s death had some similarities with a previous SAR, (Adult B) published by ESSAB in February 2020, and that this Review should also explore the extent to which previous learning had been embedded into practice.

The documents include the SAR Anna Overview Report  , SAR Anna Board Response and SAR Anna Learning Briefing

Ben was a 60-year-old man with learning disabilities, autism, paranoid schizophrenia and Type 1 Diabetes who had resided in a Care Home in Eastbourne for over 30 years.  He was admitted to Hospital with deteriorating foot ulcers requiring amputation. The severity of his condition was so extensive that amputation was not an option and he was transferred to a hospice where he sadly passed away thereafter.

East Sussex Safeguarding Adults Board (ESSAB) commissioned this Safeguarding Adults Review (SAR) to understand the circumstances leading up to Ben’s death and to support the identification of strengths and weaknesses in how agencies worked together to safeguard Ben. The Board used a hybrid approach to draw on learning from a previous SAR published by the ESSAB, known as ‘Adult A’ published in October 2017, where similarities existed with Ben’s circumstances.

The documents include the Overview report and Board Response.

The SAB commissioned this Thematic Review to understand the circumstances of four women aged between the ages of 19 to 51 years old who died between May and November 2020, either from suicide or from causes linked to drug overdoses who all experienced trauma, violence and loss in their adult lives. Whilst these four women lived in East Sussex, they did not know each other but did have contact with a number of the same health and social care services.

The review had a particular focus on specific areas including, how well services identify and respond to women with multiple complex needs who have a history of trauma and difficulties engaging with support, and whether professionals and agencies have the knowledge, skills and experience to effectively support this cohort of people.

The documents include the Thematic Review Report and SAB Response.

Thematic Review- Learning Briefing

Sadly, Charlie had a short and complex life.  He had suicidal thoughts in adolescence and significantly self-harmed on many occasions and regularly refused hospital treatment. Charlie went missing regularly and was temporarily excluded from school. He identified as male in 2019.

He was the subject of two periods in Hospital under Section 2 of the Mental Health Act due to his repeated self-harm and following the second period in hospital, Charlie was discharged to temporary accommodation in Brighton. Charlie continued to self-harm and drink significant amounts of alcohol. A short while after he moved into temporary accommodation, it is believed, that Charlie took his own life.

East Sussex Safeguarding Adults Board (SAB) and Brighton and Hove SAB commissioned this SAR to understand the circumstances leading up to Charlie’s death and identify any areas of learning to services, systems, commissioning and assurance which could help prevent similar incidents occurring.

The documents include: Executive Summary  , SAR Charlie Board Response ] and SAR Charlie Learning Briefing


The ESSAB commissioned this SAR to understand the circumstances leading up to Hannah’s death and to support the identification of strengths and weaknesses in how agencies worked together to safeguard Hannah.

Tragically, in May 2022, Hannah died as a result of a head injury she sustained at home. Hannah was dependant on alcohol at the time of her death and the physical harm caused by alcohol was significant.  She had multiple inpatient hospital admissions under several medical specialities and was taking a variety of medications and treatments. The review explored areas of learning specific to Hannah’s case:

  • Self-neglect and the harm caused by alcohol.
  • Multi-agency approaches to management of risk.
  • Consideration of carers.
  • Understanding the person.

The review also considered the degree to which this case highlights systemic issues in how the multi-disciplinary team approach complex areas of safeguarding and the need to align pathways and processes and promote awareness of them across the workforce. The case also raised the question of who we mean when we refer to a “multi-agency” team, and the challenge of coordinating such a response especially when the Local Authority are not involved remains an issue in terms of expertise and capacity.

 The documents include: SAR Hannah Overview Report , ESSAB Response SAR Hannah , SAR Hannah Learning Briefing

Tragically, in July 2021,  Donna who was a 42-year-old white British woman and alcohol dependent, died unexpectedly shortly before her 43rd birthday. Her medical cause of death was “sudden unexplained death in alcohol misuse.”

The ESSAB commissioned this SAR to understand the circumstances leading up to Donna’s death and to support the identification of strengths and areas for development in how agencies worked together to safeguard Donna.

Key findings from the review included: a lack of co-ordinated, multi-agency response to Donna’s needs and risks, opportunities to initiate safeguarding enquiries were not taken and trauma-informed practice, exploring Donna’s life experiences was not evident.

The review also brought into focus the impact of alcohol use and self-neglect.

The documents include: SAR Donna Executive Summary , SAR Donna - ESSAB Response , SAR Donna- Learning Briefing and SAR Donna Family Statement.

Unfortunately, Finley passed away in November 2021, he was in his early 30s when he died. The cause of his death was drug toxicity.

When Finley was 16, he was diagnosed with schizophrenia and spent nearly two years in an adolescent unit. He was then placed in supported housing which lasted for several years before he was given notice by the home as they could not offer the support he needed which led to him moving to private accommodation.

Finley was not always able accept the support offered by services and had misused illicit drugs for a period of time. During his final year of life, there were key indicators that substance misuse was a high risk to his safety.

The ESSAB commissioned this SAR to understand the circumstances leading up to Finley’s death and to support the identification of strengths and areas for development in how agencies worked together to safeguard Finley.

There were a number of emerging issues and learning which came out of this review including:

  • Engagement with families – when someone has fluctuating capacity.
  • Responding to indicators of cuckooing.
  • Dual diagnosis.
  • Multi-agency response to self-neglect.

The documents include: SAR Finley- Review , ESSAB Response Safeguarding Adult Review Finley , SAR Finley- Learning Briefing .

In 2021, Gwen who was a 95-year-old woman sadly died shortly after her admission to Hospital. In 2022, following a rapid decline in Ian’s mental and physical health, he was admitted to hospital and sadly died the following month.

As the circumstances of Gwen and Ian and the potential learning were similar, it was decided to undertake a joint review. Both were living at home in circumstances of self-neglect and were residing with  family who were experiencing challenges in performing caring roles. There were features of engagement difficulties experienced in limited agency involvement, as well as missed opportunities to respond to presenting needs and risks in a comprehensive and coordinated way.

The ESSAB commissioned this SAR to understand the circumstances leading up to Gwen and Ian’s deaths and to support the identification of strengths and challenges in how agencies worked together to safeguard them.

The documents include: SAR Gwen & Ian - Review , SAR Gwen & Ian - ESSAB Response and SAR Gwen & Ian - Learning Briefing