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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 (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;


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.

A 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. 

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


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 Adult A SAR – published October 2017 documents include the SAR 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 Adult B SAR – published February 2020 documents include the  SAR overview report, action plan and 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 Adult C SAR - published December 2020 documents include the overview report, learning briefing action plan and Board response which contains a statement from Adult C’s family.

An action plan is being developed and will be published on this website in the near future.

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.

SAR Anna Overview Report

ESSAB Response Safeguarding Adult Review Anna