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, 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:
- 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.
A Sussex SAR Referral Learning Briefing has been produced to support understanding of the SAR criteria and the key considerations when making a referral.
In December 2020 the Local Government Association (LGA) published a landmark study highlighting the findings of the first national analysis of SARs in England since the implementation of the Care Act. The full report and executive summary are available on the LGA website:
The LGA website also contains a range of briefings in relation to the SAR National Analysis for a range of audiences including SAB Chairs and Managers, senior managers, practitioners, as well as for individuals and families.
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.
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 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.
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 Overview report , SAR Anna Board Response and The Importance of Multi-Agency Meetings 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 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.
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.