Safeguarding Adult Reviews (SAR) Policy and Procedure

There are two types of SAR:

1. Mandatory (there is an absolute duty to carry out a SAR);
2. Discretionary (the absolute duty does not apply).

Both are statutory in nature.

The purpose of a Safeguarding Adult Review (SAR) is:

1. To establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguarding adults;
2. To review the effectiveness of procedures (both multi-agency and those of individual organisations);
3. To inform and improve local inter-agency practice.

There should be a strong focus on understanding the underlying issues that informed agency/professionals’ action and what, if anything prevented them from being able to support and protect the adult who was at risk of harm or abuse.

The purpose of a SAR is NOT:

1. To hold any individual or organisation to account;
2. To reinvestigate or apportion blame;
3. To address professional negligence.

Other processes exist for that purpose including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation run by the Care Quality Commission (CQC), the Nursing and Midwifery Council, Social Work England, the General Medical Council etc.

It is acknowledged that all agencies may have their own internal/statutory review procedures to investigate serious incidents. This policy and procedure is not intended to duplicate or replace these.

The SAR process will try (where possible) to streamline and work alongside other processes, but a SAR has a clear mandate for being about learning and not about blame or accountability.

Positive outcomes and good practice

The SSAB recognises it’s important to learn when things haven’t gone well but it’s equally important to learn from when things have gone well and identify examples of good practice.

As a result, the SSAB has developed a ‘Positive Outcome and Good Practice Review Guidance and Referral Document’ so the SSAB can promote and share learning on what works well and examples of good practice that is taking place across the partnership. This can be found in the Contacts and Practice Resources area.

SARs should focus on the six key principles which are embedded into The Care Act. These apply to all health and care settings, and they should underpin all adult safeguarding work as stated in the Care and Support Statutory Guidance:

The following table sets out how the 6 principles should be applied to all SARs in Salford:

For more information about the 6 key principles to safeguarding see: Safeguarding (Care and Support Statutory Guidance). 

There will be occasions when the SAR relates to an adult that is still alive. In those circumstances all of the overarching aims, duties and principles of adult safeguarding apply.

See: Overarching Aims, Duties and Principles.

Also remember the Seven golden rules for information sharing. See: Information sharing and confidentiality.

In circumstances when the adult is still alive, careful consideration needs to be given to how the SAR should be completed, and safeguarding of the adult should remain paramount.

A mandatory SAR is a SAR that must be carried out because the absolute duties set out in sections 44 (1), (2) and (3) of the Care Act 2014 apply:

1. There is a reasonable course for concern about how the SAB, its members or other persons involved worked together to safeguard the adult; and
2. The adult has died, and it is known or suspected that the death resulted from abuse or neglect; or
3. The adult is alive, but it is known or suspected that they have experienced serious abuse or neglect.

Note: It is irrelevant whether or not the adult is known to the local authority, or whether or not they are being provided with support or services to meet their care and support needs.

With regard to 2. above, indicators that this condition is met could include:

• The adult would have been likely to have died but for an intervention;
• The adult has suffered permanent harm;
• The adult has reduced capacity or quality of life (whether because of physical or psychological side effects) as a result of the abuse or neglect.

A discretionary SAR is a SAR that is carried out when the absolute duty to do so (set out above) does not apply. Under Section 44, (4) the Care Act SABs are free to arrange for a discretionary SAR to be carried out in any other situation involving an adult in its area with needs for care and support where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect, and can include exploring examples of good practice that can be applied to future cases.

“A SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) and where it believes that there will be value in doing so.

This may be where a review can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect and can also include examples of good practice.”

 For guidance on decision making following a SAR referral see section 4. below.

A referral should always be made when the criteria for a mandatory or discretionary SAR to be carried out is met.

Other circumstances when a referral should be made

Regulation 28 notices 

Salford Safeguarding Adults Board (SSAB) requires that all Regulation 28 notices issued by the coroner are referred as a SAR for consideration, this follows the principle that if the coroner has deemed there to be single or multi-agency learning in relation to an adult with identified safeguarding concerns, then the SAR panel should be made aware of the Regulation 28 to consider whether the criteria for a SAR has been met and whether there has been any identified learning that needs to be disseminated across partner agencies.

More than one review process criteria met

Where the adult meets the criteria for more than one review process, such as a Domestic Homicide Review (DHR), Serious Incident (SI) or a Child Safeguarding Practice Review (CSPR), a referral should be made to both review processes so that the relevant boards/partnerships can work together to identify the most appropriate method to conduct the review, and the SSAB will explore the possibility of commissioning the review jointly.

This will ensure that all aspects of the review are addressed and that the identified process dovetails with any other investigations that are on-going.

Salford Safeguarding Adult Board (SSAB) and Salford Safeguarding Children’s Partnership (SSCP) business units have worked together to align the SAR referral process and SSCP Practice Review referral pathways to ensure the processes effectively enables partners to make timely decisions and avoid duplication especially when requesting single agency information that involves both an adult(s) and children.

For further information there is a flowchart in the Contacts and Practice Resources that demonstrates the connectivity between the SSAB, CSP and SSCP.

Duty of Candour 

Part 2, Section 81 of the Care Act 2014 refers to the Duty of Candour. 

Section 20 of the Health and Social Care Act 2008 (Regulation of Regulated Activities) states:

"5A. Regulations under this section must make provision as to the provision of information in a case where an incident of a specified description affecting a person’s safety occurs in the course of the person being provided with a service."

SSAB members agree to a culture of openness, transparency, and candour within their day-to-day work and with the work of the SSAB.

Partner agencies also need to ensure that staff understand their responsibility to report all incidents that meet the criteria for a SAR. The SSAB will routinely assure itself that mechanisms are in place to respond to single and multi-agency concerns.

Every agency has a responsibility for identifying its own learning and multi-agency learning.

Any agency or professional may make a referral.

When making a referral for consideration for a SAR, information about the adult will be requested on the referral form which is needed to support the screening process.

All referrals for consideration for either a SAR or a Positive Outcome and Good Practice Review should be sent to sar.referrals@salford.gov.uk.

For guidance on making a referral and decision making, see Overview of the Salford Process – Referral to Decision Making. This can be found in the Contacts and Practice Resources area. 

Please be aware by making a SAR referral, it doesn’t automatically mean the criteria/conditions have been met and a SAR will be arranged; there is a clear process, as detailed in this policy and procedures regarding the process to determine whether the criteria has been met.

SAR flowchart 

Decision making responsibility

All referrals should be reviewed by the Safeguarding Adults Board (SAB) to ensure that the conditions for carrying out a Safeguarding Adults Review (SAR) have been met or not.

In Salford, there is a SAR Panel acting on behalf of the SSAB, membership of this subgroup is from key partners that include:

• Local Authority – Salford City Council;
• Adult Social Care – Northern Care Alliance – Salford Care Organisation;
• Greater Manchester Mental Health Trust (GMMH);
• Northern Care Alliance (Health – Acute and Community);
• Greater Manchester Police (GMP);
• NHS Greater Manchester Integrated Care (Salford locality).

In addition, the SAR panel should invite any other relevant professionals or agencies who may be involved with the named adult, the SAR Panel also have links with the Governance Managers (to connect with the Serious Incident Process) and other partner agencies e.g., Housing Services.

The Independent Chair of the SAB is ultimately responsible for making any final decisions however, wherever possible all members of the board should be in agreement.

The decision making process 

When a referral is received, single agency information should be requested to support the SAR Panel in making a decision to whether the criteria for a SAR has been met or not.

The SAR Panel meets on a monthly basis to consider all the SAR referrals.

Additional meetings should be convened, if necessary, to ensure referrals are considered in a timely manner.

A Decision-Making Flowchart has been developed to support the SAR panel members with the decision making to ensure the legal framework is being applied. This can be found in the Contacts and Practice Resources area. 

The outcome from the SAR Panel will be one of the following:

• Mandatory SAR - Care Act 2014, section 44 (1), (2) and (3);
  
  Statutory duty has been met.
  
  
• Discretionary SAR – Care Act 2014, section 44 (4);
  
  Section 44 (1), (2) or (3) is not met but the SAB feels there is multi-agency learning or evidence of good practice that needs to be shared and applied in the future;
  
  Both Mandatory and Discretionary SARS are a statutory duty under the Care Act 2014.
  
  
• Area of assurance or agreed actions to be taken forward by single agency or the SSAB;
  
  The SAR Panel may wish to seek assurance on a certain aspect of practice relating to the information that has been presented to the panel.
  
  
• No SAR;
  
  Criteria/conditions for a statutory review haven’t been met;
  
  No further action will be taken by the SSAB.
  

Note: The outcome of the SAR decision should not prevent any internal review, complaints process, actions from Section 42 Safeguarding Enquiries or any other internal review or process from being taken forward or completed.

The decision as to whether the criteria for a SAR has been met (or not met) should be recorded in SAR Panel minutes and the SAR summary document. The record should give a clear rationale for the decision making to provide clarity and transparency in the decision-making process.

When a SAR is not to be carried out

In the event of a SAR referral being rejected, the reason/s that conditions have not been met should be clearly recorded. In particular, if there is no duty to carry out a mandatory SAR, the reason that a discretionary SAR is not being carried out should be clear.

Notifying the referrer

The referrer must be notified of the decision made by the SAR panel.

If the referrer is dissatisfied with the decision, they can firstly discuss their concerns with the named SAR Panel member for their agency or alternatively with the Business Manager of the SSAB, if they remain dissatisfied, they can discuss their concerns with the Chair of the SAR Panel and/or the Independent Chair of the SAB.

The following represents what was agreed in the Greater Manchester SAR Policy.

There will be cases where adults have moved from their 'home' area and may be placed and funded by an organisation that is outside the provider’s area. If that is the case, a SAR should be carried out by the SAB that is responsible for the location where the adults care and support needs are met and/or where the serious incident took place. Discussions will be needed to ensure SABs and organisations should cooperate across borders, and requests for the provision of information should be responded to as a priority. When there is an adult who has no commissioned support in place, a sensible and proportionate approach is needed, and the lead SAB should be where the adult is best known.

If agreement cannot be reached on the requirement for a SAR to be undertaken then this will be resolved in the first instance by the relevant Board Managers, with ultimate decision making and discussion being resolved by the Independent Chair of the SAB. Independent Chairs will agree on the mechanisms for presenting SARs that have cross border learning.

Once a SAR is agreed, the support team for the SSAB will take the lead on managing the SAR process. See section 5 for guidance.

There will also be a need to address the budgetary requirements for undertaking the SAR. This is the responsibility of the Chair of the SAB.

The SAR should be completed within a reasonable period of time and in any event within six months of initiation, unless there are good reasons for a longer time period. Any delays in the process must be clearly documented with the reasons why within the SSAB SAR Summary Document.

The Care and Support Statutory Guidance gives Safeguarding Adult Boards the flexibility to choose their own methodology to ensure a streamlined and proportionate approach to how a SAR is undertaken. As such, the Safeguarding Adults Review (SAR) Panel should determine what process each SAR will follow.

The approach should be proportionate to the scale of the abuse or neglect that has occurred, the impact on the person and the level of complexity in the issues to be examined during the review.

Once the SSAB Chair has confirmed and agreed with the recommendation that a review should be undertaken for the named adult and agreed with the preferred methodology to be used, the following need to be put in place:

• A multi-agency SAR Review Group which offers independence in the review process;
• A lead reviewer (either commissioned or appointed from within the Salford Partnership if appropriate);
• A Chair for the Multi-Agency Review Group will be identified - this could be the lead reviewer but in Salford for mandatory SARs it tends to be the Chair of the SAR Panel.

If an Independent Reviewer is required, an invitation to tender letter should be shared across the National Group to ensure an Independent Reviewer with the right knowledge, experience and skill set is commissioned to undertake the review.

Once an Independent Reviewer has been identified, a commissioning letter should be shared to confirm the commissioning arrangements and agree cost for the review. This letter will need adapting according to the individual circumstances of the review.

The SAR Review Group

The chair of the SAR Review Group and core members need to have sufficient independence from the named adult.

The SAR Review Groups role is to oversee the governance of a particular review – the group should have a senior representative from each of the provider services involved but this representative must not (where possible) have actually been involved with the name adult.

There may be occasions when a representative identified to be on the review group may have had some involvement within the named adult. At the planning stage of the review, all members of the review group will be asked if they have any declaration of interests, which will be recorded centrally and then be shared with the wider review group to ensure transparency throughout the review process.

For further information please refer to the Declaration of Interests Process and Form. This can be found in the Contacts and Practice Resources area.

The role and responsibilities for members of the multi-agency SAR review group are clearly defined in the Terms of Reference of the SAR. It’s the responsibility of the individual agency to feed back to their senior leadership team to keep them updated on the progress of the SAR to ensure there is clear communication and connectivity to Senior Leaders within their own organisation.

The image below explains some of the roles and responsibilities of the Multi-Agency SAR Review Group:

The members should be kept up to date on the progress of the SAR and attendance to the SAR Review Group is important to ensure individual members continue to have oversight of the progress of the review and have sight of the developing report.

When the SAR process is coming to an end, all review members are expected to confirm and agree the contents of the final draft prior to it to being submitted to the Independent Chair/SSAB for approval and acceptance.

If during the review, further information or issues emerge that require notification to a statutory body (for example the Care Quality Commission, Department of Health and Social Care, Department for Education, Health and Care Professional Council, The Nursing and Midwifery Council, Home Office, General Medical Council, Health and Safety Executive) this should be reported to the Chair of the Adult Safeguarding Board straight away. They will agree how to proceed and who will make the notification. This could be regarding significant omissions by individuals or organisations.

They will also make the decision about whether the SAR needs to be suspended during such a notification.

The lead reviewer

The lead reviewer must have appropriate skills and experience which should include:

1. Strong leadership and ability to motivate others;
2. Expert facilitation skills and ability to handle multiple perspectives and potentially sensitive and complex group dynamics;
3. Collaborative problem-solving experience and knowledge of participative approaches;
4. Good analytic skills and ability to manage qualitative data;
5. Safeguarding knowledge.

The SSAB Business Manager & Senior Administrator

The SSAB Business Manager will work closely with the Senior Administrator to co-ordinate the SAR process outlined in this policy and ensure that identified time frames are adhered to.

In all reviews

The SAR Panel should ensure that all relevant persons are involved.

For example:

1. Professionals involved with the adult;
2. Organisations involved with the adult;
3. Family members;
4. Carer's (informal and paid).

In some SARs, it may be deemed necessary to also involve the person who caused (or is suspected of causing) the abuse or neglect.

Involving the adult and their family/representative

Adults and/or families should be invited and supported to contribute to SARs if they wish to do so, in order that an inclusive approach is taken and that their experience, wishes, feelings and needs are placed at the heart of the review.

The Business Manager should consider making contact with the adult(s), their family and/or representatives at the earliest opportunity. If deemed appropriate, and there are no other formal investigations to consider, contact should be made during the screening process for the SAR Panel to have an understanding of how they felt partners worked together.

There is an Information Sheet available which is accessible for the adult, families or the representative which provides information regarding what is a SAR, the process of a SAR, the relevant contact details for the support team for the SSAB and also forms of external support which is available because its acknowledged that being involved in a SAR process can be difficult and impact on a person’s emotional well-being.

See: Information for the adult and their families.

Reasonable and appropriate support and adjustments should be made as required to enable the adult(s), their family and/or representatives to participate in the SAR. This may include, but is not limited to:

• Easy read, large print and/or translated materials;
• Access to an interpreter;
• Support from a chosen chaperone or representative;
• Longer meeting times;
• Pre-meeting briefings and post-meeting de-briefs;
• Access to a statutory independent advocate.

Advocacy and Support

If the adult is alive there is a statutory duty to ensure they receive the support they need to enable them to understand and/or participate in the SAR process.

If they are already in receipt of advocacy support under Section 67 of The Care Act, The Mental Capacity Act 2005, or the Mental Health Act it is appropriate to establish whether the existing advocate is able to provide this support.

Otherwise, the duty to appoint an advocate under Section 68 of the Care Act must be considered.

For further information about the duty to appoint an independent advocate see: The Duty to Provide an Independent Advocate.

Involvement of practitioners/frontline staff

It is really important to ensure each SAR supports practitioners who were involved with the named adult have the opportunity to engage within the review process.

The practitioners should feel that they will contribute to the review without the fear of any blame and to embrace the experience as one of being about reflection, personal development learning and an opportunity to influence positive change in the wider system.

There will be an open and honest approach so the nature, scope and timescale of the review should be made clear at the earliest possible stage to the practitioner that’s invited to contribute to the review.

It is important that all relevant practitioners, staff and volunteers of agencies are given an opportunity to share their views about their experience with the adult as appropriate to the review methodology which has been selected. The methods used to do this will be determined by the multi-agency review group.

The death or serious injury of an adult at risk will have an impact on staff and volunteers and needs to be acknowledged by the agency. The impact may be felt beyond the individual staff and volunteers involved, to the team, organisation or workplace. Therefore, individual agencies need to take responsibility to ensure their own staff and volunteers are provided with a safe environment to discuss their feelings and offer support where needed.

The support team for the SSAB have produced some guidance to enable staff and volunteers to understand the purpose of a Practitioners Reflective Session. This along with other resources can be found in the SAR section of the Contacts and Practice Resources area.  

When instigating a Safeguarding Adults Review (SAR), the Safeguarding Adults Board (SAB) should establish if any other relevant investigations are/will be taking place in parallel to the SAR. For example a:

1. Child Safeguarding Practice Review (CSPR) (previously known as a Serious Case Review);
2. Domestic Homicide Review (DHR);
3. Criminal investigation;
4. Coroner's Inquest/Enquiry.

The Independent Chair of the SAR Panel should make contact with the Chair of any parallel process to agree on how best to avoid duplication for the adult (if they are alive), families, professionals, and organisations. This should include how to share relevant information in a timely way, in line with Data Protection legislation and local information sharing policy.

If the SAR Panel requests a person or organisation to supply information to support the process, they have a duty to comply with that request under s45 of the Care Act.

All information sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

The purpose of a SAR is not to apportion blame to an individual or an agency but to learn lessons for future practice. It is important that this message is conveyed to staff and volunteers.

However, issues of professional conduct may become apparent during a SAR, but it is not within the remit of the SAR panel to deal with these.

Where concerns about an individual’s practice or professional conduct are raised through the SAR process, they must be fed back to the relevant agency through the Chair for the SAR Review Group.

It then remains the responsibility of the individual agency to trigger any action in proportion with the concerns passed on by the SAR Review group.

Once the final report has been approved and accepted by the Independent Chair/SSAB, the report will be shared with the following to ensure they have oversight and to start sharing the learning:

• Briefing Document to be presented to the DASS and senior leaders across partner agencies;
• Wider Learning Event to share the learning across the partnership;
• Link to the final report/Briefing Document to be published in the SSAB website and shared within the SSAB newsletter.

SSAB members will be asked to share the learning within their own organisations.

The link to the published report and supporting tools will be shared with:

• Other Boards/Partnerships (if appropriate);
• Greater Manchester and National SAB Forums;
• Share with the National Database - if appropriate.

A copy of the report should be provided to anyone who has requested it, particularly the adult (if they are alive), and their family (if involved in the SAR).

The Chair of the SAB should take steps to ensure the adult (if they are alive) and their family understands the findings of the report and the recommendations it has made.

SAR's involving CQC registered providers 

If the SAR has explored the practice of a care provider regulated by the Care Quality Commission (CQC), a copy of the report should be provided to the CQC. Copies of any specific documentation or evidence submitted by the care provider as part of the SAR should also be provided to the CQC if it is requested.

All final reports should be published on the Safeguarding Adults Board website.

When agreed by the Independent Chair/SSAB, overview reports can be shared with the National database to ensure wider learning.

See: Published SARs and other reviews.

Any actions should be recorded in an Action Plan. It should be clear which agency/organisation is responsible for carrying out each action and timeframe for having done so.

The SAR Panel is responsible for reviewing the Action Plan and monitoring progress of the actions.

In line with Schedule 2 of the Care Act, the following information from each Safeguarding Adults Review (SAR) must be recorded in the annual SAB Report:

1. The findings of the SAR;
2. What actions have been taken (or will be taken) in relation to those findings;
3. Where a recommendation has not been implemented, the reason/s for that decision.

See: About the Safeguarding Adults Board - Annual Report.

Each year, designated SSAB members from a range of agencies will meet at the end of the reporting year to review collective data, themes, trends and learning from the reviews undertaken for the reporting year.

The aim of this thematic review is to ensure there is transparency in learning through the reviews that have been completed and clear understanding what positive impact the actions and learning has had on current practice and identify where there continues to be areas of development.

The support team for the SSAB will maintain a database which will be used to collect to enable data to be analysed and aid in-depth discussions.

A summary from the thematic review will be presented to the SSAB and any other relevant subgroups.

For a copy of the annual thematic reviews on SARs please see: Published SARs and other reviews.