Safeguarding Adult Reviews (SARs)

What is a SAR?

The Care Act 2014 introduces statutory Safeguarding Adults Reviews (previously known as Serious Case Reviews), mandates when they must be arranged and gives Safeguarding Adults Boards flexibility to choose a proportionate methodology.

This policy and procedures have been developed in light of the Care Act 2014 and Chapter 14 of the supporting statutory guidance and outlines a referral pathway, the convening of the SAR panel and guidance to the SAR panel on making recommendations to the Independent Chair.

The Care Act 2014 puts in place a new framework with statutory duties for adult safeguarding which is supported by the Care and Support Statutory GuidanceSection 14.162 sets out further guidance for what action should be taken when a SAR is undertaken. 

The Care Act 2014 Section 44 states that Safeguarding Adult Boards (SAB) must 

(1) Arrange for there to be a review of a 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) if—

(a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and

(b) Condition 1 or 2 is met.

(2) Condition 1 is met if—

(a) The adult has died, and

(b) 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).

(3) Condition 2 is met if—

(a) The adult is still alive, and

(b) The SAB knows or suspects that the adult has experienced serious abuse or neglect.

(4) An 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).

(5) Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to—

(a) Identifying the lessons to be learnt from the adult’s case, and

(b) Applying those lessons to future cases.

Salford Safeguarding Adults Board (SSAB) requires that all Regulation 28 notices issued by the coroner, where there is a safeguarding aspect to the case, should be referred into the SAR panel for consideration.  This follows the principle that if the coroner has deemed there to be single or multi-agency learning in relation to a case with identified safeguarding issues, then the SAR panel should be made aware of this case to consider identifying and disseminating the learning across partner agencies as appropriate.

Where a case meets the criteria for more than one review process, such as a Domestic Homicide Review or a Child Practice Review, a referral should be made to both review processes so that the relevant boards can work in partnership to identify the most appropriate method to conduct the review, and 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 summaries for a case that involves both adult and children.

Learning lessons - SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again.

It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them. If individuals and their organisations are fearful of SARs their response will be defensive and their participation guarded and partial.

Its purpose is not to hold any individual or organisation to account. Other processes exist for that, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council

The following principles apply to all reviews:

  • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the wellbeing and empowerment of adults, identifying opportunities to draw on what works and promote good practice
  • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined
  • The individual (where able) and their families should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively
  • The Safeguarding Adults Board is responsible for the review and must assure themselves that it takes place in a timely manner and that appropriate action is taken to secure improvements in practice
  • SARs should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed
  • Professionals/practitioners should be involved fully in reviews and invited to contribute their perspectives.
  • SAR’s should be completed in a timely manner; and within six months of when they are commissioned unless there is a reason for a longer period e.g. ongoing court proceedings. Any positive or negative delays will be recorded on the SAR summary document, Appendix 5.
  • The findings from any SAR may be published on the SSAB website, reported in the SSAB Annual Report along with the actions taken in relation to those findings and reviewed through a SSAB annual thematic review.

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

In section 20 of the Health and Social Care Act 2008 (regulation of regulated activities), after subsection (5) —

(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 agreed 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.

Consideration must be given to the type of review process that will promote effective learning and improvement action that will prevent future deaths or serious harm occurring again. No one model will be applicable for all cases. The SAR panel will need to weigh up what type of review process is proportionate to the case and will promote effective learning and improvements in practice to prevent future deaths or serious harm occurring again.  More on different methodologies can be found in section 8.5.

The focus must be on what needs to happen to achieve understanding, remedial action and, very often, answers for families and friends of adults who have died or been seriously abused or neglected.

A range of possible methodologies can be used for a SAR. Each methodology is valid in itself, and no approach should be seen as holding more importance or value than another. The methodology for the review will need to be agreed by the independent chair and SSAB members.

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