Safeguarding Adult Reviews (SARs) - The SAR process

The information in the tabs below explains the process of completing a safeguarding adult review (SAR) from submitting a referral through to the methods which might be used to complete the review.

Who can make a referral?

Any agency can make a referral for a SAR if they identify a case where they believe that the criteria for a SAR are met (see section 2 of the SAR policy).  Examples of how a case might be identified are:

  • During a safeguarding enquiry an Enquiry Officer or Chair identifies a case;
  • An agency may identify a case that hasn’t had a safeguarding enquiry e.g. police may identify that a case they have been investigating meets the criteria for a SAR
  • The Coroner, MP’s and Elected Members of Salford City Council may have a case brought to their attention where they feel a SAR referral is appropriate or when a Regulation 28 has been issued.
  • Referrals can be made by family members, carers and members of the public
Making a referral

Requests for a SAR must be made in writing using the SAR referral form which should be completed as fully as possible and returned to Salford Safeguarding Adults Board via the SAR email address

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; practice that has been proven to work well and produce good results and outcomes for people. Therefore the SAR Panel would also like to be alerted and learn from cases that have gone well to ensure the good practice can be shared across agencies.

As a result, a Positive Outcome and Good Practice Review Guidance and Referral document has been developed

Escalation through internal management structure

Where a professional or volunteer working for an agency has identified a possible SAR referral, the case should first be considered internally within the organisation at the appropriate level. Each agency/organisation needs to decide how any SAR referral will be verified internally before the referral is made to the Safeguarding Adults Board. This process should be clearly communicated to staff and noted in any single agency safeguarding adults policy.

Internal reviews

If the incident triggers a mandatory investigation or review within the organisation concerned (e.g. NHS serious incident investigation or Coroner’s Reg 28 notice) this should take place as a matter of priority, but a referral for a SAR (if appropriate) should not be delayed and should be made at the same time. Internal governance processes and multi-agency reviews are not mutually exclusive.

How a SAR referral is processed:
  • SAR referral is sent to
  • SAR referral is screened within 1 working day
  • SSAB Business Manager makes an assessment whether additional information is required or decides whether the referral needs to go to the next SAR panel.
  • The SSAB complete a SAR Summary Document (read only) and a chronology is created to evidence action and decision making
  • A Single Agency Summary Proforma document is sent out to identified agencies for completion outlining their involvement with the identified adult.
  • Please note in some cases this may not be deemed necessary for the SAR panel to make a decision.
  • Case summary proforma to be returned within 10 working days.
  • Returned case summaries will be collated and SAR referral will be scheduled for consideration by the next scheduled SAR panel
  • The SAR panel, acting on behalf of the SSAB, will make a recommendation to the Independent Chair if they feel a review should be conducted (either a mandatory or discretionary review)
  • SAR summary document to be completed and the decision from the SAR panel will be shared with the referrer to advise them of the outcome of the referral.
  • The Independent Chair will make the final decision
  • All SSAB members will be given the opportunity to comment on the appropriate methodology for any SAR agreed.
How is the decision communicated?

The SAR Summary Document  will be shared with the referrer, relevant statutory Directors and the Independent Chair to advise and notify them of the decision to undertaken a review either mandatory or discretionary.

The designated safeguarding lead in the NHS Greater Manchester Integrated Care will provide single point of contact for informing/notifying other health providers.

A central log of SAR referrals and agreed outcomes will be held by Salford Safeguarding Adults Board.

Further options if a request for a SAR is turned down
  • If a request for a SAR is turned down, and where the requestor is dissatisfied with this outcome, they should notify the Chair of Salford SAB in writing (via the SSAB Business Manager), who will discuss and review (if necessary) the decision with the requestor and the sub group of Board members who decided on the initial request
  • If a decision not to hold a SAR is upheld, the requesting agency can choose to take no further action or to undertake an internal review using an appropriate methodology
  • Any actions from a Section 42 Safeguarding enquiry must continue to be implemented along with any actions in the protection plan.


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.

NHS Greater Manchester Integrated Care have agreed a protocol and form for requesting information in out of area SAR referrals.

SAR Panel

The SAR panel, which is a subgroup of the SSAB, has 12 scheduled meetings a year to review SAR referrals and make a decision on behalf of the SSAB.

Additional meetings can be convened if necessary, to ensure that referrals are considered by the panel within the time frames outlined in this policy.

This subgroup is made up of SSAB members or agency representatives at an appropriate senior level. Core membership comprises a member from NHS Greater Manchester Integrated Care, GMP, Adult Social Care, GMMH, SRFT and the Local Authority, and there must be core membership for the panel to be quorate.

The SAR panel is chaired by a SSAB member from one of the core partner agencies. Other panel members can deputise in the chair's absence.

During the screening process of the SAR referral, if it’s identified that additional information is needed by an external agency or another representative who ordinarily isn’t a SAR panel member then an invite will be sent by the support team for the SSAB for the agreed person to represent the SAR panel, as required.

It must be remembered that the SAR panel is a supportive process and not a scrutiny of practice.

There is a 7-minute briefing that provides an overview of the SAR process which can be found on the SSAB website.

The role of the SAR panel – reviewing all SAR referrals

The primary role of the SAR Panel is to consider all SAR referrals to determine if there is a statutory obligation to conduct a SAR (i.e. whether the referral meets the criteria outlined in 2.1.1 or 2.1.2 of this policy).

Mandatory SARs

A SAR must be commissioned if there is a statutory requirement to do so when all the criteria and conditions have been met.

Discretionary SARs

A discretionary SAR may be needed where part of the criteria/conditions have been met and the panel feel there is multi agency learning.

The SAR panel will carefully consider whether requesting a discretionary SAR would be a worthwhile exercise: i.e. if a multi-agency review process has the potential to identify sufficient lessons to enhance partnership working, improve outcomes for adults and families and prevent similar abuse and neglect in the future.

The Chair of the SAR panel should also consider whether another review or learning process has already been commenced that will identify and share lessons to be learned, or which the SSAB could potentially feed into to avoid duplication (e.g. Domestic Homicide Review or Serious Incident process).

The SAR members use a decision-making tool which supports them to make a decision to whether a mandatory, discretionary review or no review is required.

The role of the SAR panel - oversee all SAR reviews

The SAR panel will also maintain oversight of any on-going reviews (mandatory or discretionary) that the panel has recommended to ensure that actions are identified and learning appropriately disseminated.

SAR Panel Decision – reaching a consensus

In deciding on a recommendation to the Independent Chair to undertaking a SAR (mandatory or discretionary), the SAR panel should aim for consensus, not a majority view. If the sub group cannot come to a consensus, then the SSAB Independent Chair must be made aware of this and the differing views so that they can be fully aware of all perspectives in making the decision. The discussion within the SAR panel will be recorded and minutes shared but a summary of the discussion and decision making will be recorded in the SAR summary document.

Making Decisions on SAR methodology

The SAR panel should consider and recommend an appropriate methodology for the SAR with their recommendation to the Independent Chair. There should be a brief rationale for this, outlining why their choice is appropriate and the most proportionate to the case under review, this will be recorded in the SAR summary document. If the decision of the Independent Chair is that a SAR will be commissioned, then SAR Panel members should be consulted regarding the methodology and commissioning options available.

Information about different review methodologies can be found on the SCIE website, however there is a drive at a National level to speed up the process with the introduction of Reviews in Rapid Time

The SSAB has begun to adopt this approach.

The final decision

The final decision to conduct a SAR is made by the SSAB Independent Chair considering the rational and recommendations of the SAR panel.

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

  • A 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 Review Panel Chair (this could be the lead reviewer but would usually be the SAR Panel Chair )

If an Independent Reviewer is required, a commissioning letter should be used to confirm the commissioning arrangements. This letter will need adapting according the individual circumstance of the review.

The Review Panel

The Review Panel chair and core members needs to have sufficient independence from the case. The SSAB chair will invite the preferred candidate to chair the panel and brief them on the agreed methodology, Terms of Reference and required timescales.

The Review Panel will oversee the governance of this particular review – the group should have a senior representative from each of the provider services involved but this representative must not have actually been involved in the case. There may be occasions when the representative may have had some involvement within the case so declaration of interests will be requested and disclosed to the wider group to ensure transparency throughout the review period.

Membership should also include a representative from each of the core partnership agencies with appropriate seniority and experience with regard to the case under review. Other review team members could include partner agencies not involved in the case who will bring a different perspective to the group e.g. commissioners or a voluntary sector partner.

From February 2021, the SSAB has introduced a process for managing a declaration of interest in a SAR.

Responsibilities of the Review Panel

  • Determine the TOR which include timescales for completion, how learning will be disseminated
  • Consider system issues as well as individual practice
  • Consider cooperation with SCRs and DHRs
  • Scrutinise relevant policies and practices
  • Gather the evidence
  • Involve the family
  • Agree final version of the report
  • Agree the key points for reports and action plans
  • Identify good practice as well as areas for improvement
  • Pay attention to Data Protection, Freedom of Information and the Human Rights Act.

If during the review, further information or issues emerge that require notification to a statutory body such as: 

  • 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 and they will agree how to proceed and who will make the notification. This could be regarding significant omissions by individual or organisations.

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

Role of 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.

If a SAR or other review is agreed by the SSAB Independent Chair then additionally the Business Manager will support with the commissioning of the Independent Reviewer if necessary and co-ordinating the ongoing work of the Review Team.

Adult and/or family involvement and independent advocacy
  • 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 must attempt to make contact with the adult(s), their family and/or representatives early on (ideally before the first SAR Review Group meeting) to establish:
    • Why and how a SAR will be undertaken into their (family member’s) case.
    • How they would like to be involved e.g. views contributed via telephone conversation, or interview, or attendance at SAR meetings.
    • Any support or adjustments they would need to facilitate their involvement.
    • Their initial views, wishes, concerns, and any answers/outcomes they would like to achieve from the SAR

A template letter can completed and sent to the adult, family or adult representative.

There is an Information Sheet available for the adult, families or the representative of the adult to enable them to understand the SAR process which provides the relevant contact details for the SSAB business unit and also forms of external support which is available because its acknowledged that being involved in a SAR process could have an impact on a person’s emotional well-being.

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.

If there is no appropriate person to support and represent the adult(s), then Salford SSAB must arrange for an independent advocate (under Section 68 of the Care Act). Arrangements should be made in line with Salford’s standard policy and procedures for arranging advocacy.

Alternatively, if the relevant criteria are met, appropriate partners can arrange for an independent mental capacity advocate (IMCA) or an independent mental health advocate (IMHA), or a non-statutory advocate to support and represent the adult(s). If an independent advocate, IMCA or IMHA has already been arranged for the adult(s), e.g. during assessment and care support planning or for a safeguarding enquiry, then the same advocate should continue to be used.

Staff involvement

As soon as the decision to conduct a SAR has been made, staff and volunteers that have had involvement in the case should be notified of this decision by their agency. The nature, scope and timescale of the review should be made clear at the earliest possible stage to staff, volunteers and their line managers. It should be made clear that the review process can be lengthy.

It is important that all relevant staff and volunteers of agencies are given an opportunity to share their views on the case as appropriate to the review methodology selected. The methods used to do this will be determined on a case by case basis by the review team. This should include their views about what, in their opinion, could have made a difference for the adult(s) and/or family.

All agencies must support staff and practitioners involved in a SAR to “tell it like it is”, without fear of retribution, so that real learning and improvement can happen. Agencies are responsible for ensuring their own staff and volunteers are provided with a safe environment to discuss their feelings and offered support where needed. 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 maybe felt beyond the individual staff and volunteers involved, to the team, organisation or workplace.

The support team for the SSAB have produced some guidance to enable staff and volunteers to understand the purpose of a Practitioners Learning Event. 

Professional conduct issues arising

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. 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.

The Lead Reviewer

The lead reviewer leads the review and writes the final report with recommendations that go to the SSAB. The lead reviewer is either commissioned or appointed by the SSAB Business Manager in consultation with the SAR Panel. The SSAB has ownership of the report and the SAR panel writes the action plan on behalf of the board and oversees it implementation.

SAR Report

The Chair and SAR Panel members are responsible for ensuring the Review Report and Public Summary are drafted and delivered within timescales, and are consistent with the terms of reference. 

The Report should bring together all the relevant information with an analysis of events, and should include recommendations, where appropriate. The report should cover:

  • An account of events and factual findings with a chronology developed from individual management reviews already submitted;
  • Any matters of concern affecting the safety and wellbeing of adults at risk;
  • Any general public health, safety or wellbeing issues arising from the death of an adult at risk;
  • Any need to review policy, practice or procedures;
  • Dissemination to other Local Authorities;
  • Identification and integration of learning points from published Safeguarding Adults Reviews from other areas of research and best practice guidance;
  • Information on references and sources used to prepare the report.
When the report is considered to meet the requirements, the SAR Panel will:
  • Send a draft of the report and invite contributing agencies for comments on factual accuracy to ensure the information is fully and fairly represented.
  • Invite agencies to confirm that the draft recommendations, as they apply to their agency or more generally, are clear.
  • A copy of the draft report is shared with the family/adult representative and invite an opportunity to make comment on the factual accuracy.

It is important to note that agencies are not being asked whether they agree with the report or its findings. The focus is on ensuring the report is factually accurate, understood and recommendations are clear. Agencies have 10 working days to respond.

A confidentiality agreement will be signed before the draft report is shared with anyone outside of the review panel to ensure there is an agreement that the content or the document will be not shared prior to approval from the SSAB and publication.

The Panel will consider all comments and agree the final version of both the Review report and public summary to be submitted to the SSAB for sign off.

The SAR Panel will translate learning from the report into recommendations and a proposed multi-agency action plan if required after the report has been agreed by the SAB. The action plan should be endorsed at senior level by each organisation to whom it relates.

The multi-agency action plan will indicate:

  • The actions that are needed.
  • Responsibilities for specific actions.
  • Timescales for completion of actions.
  • The intended outcomes: what will change as a result/ what difference would an action have made to the person concerned.
  • Mechanisms for monitoring and reviewing intended improvements.
  • The processes for dissemination of the SAR report or its key findings.
  • Individual agencies may also be asked by the SSAB to produce their own internal action plans if required.

The SAR Panel will monitor that all actions are completed from their own and the multi-agency action plan, and for ensuring that learning from the SAR is embedded in their organisation and constituent agencies. However, agencies should make every effort to capture learning points and take internal improvement action where possible while the SAR is in progress, rather than waiting for the SAR report and action plan. The SAR Panel will decide on appropriate time frames for each review action plan, this should not exceed 12 months for completion.

Each year, designated SSAB members from a range of agencies will meet towards the end of the reporting year (between Feb and March) to review collective data, themes, trends and learning from the reviews undertaken for the reporting year, the aims of this group 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 shared with the SSAB and any other relevant sub groups.

In line with Schedule 2 of the Care Act, Salford SAB will include findings from any SARs in its annual report, and information on any on-going SARs. The annual report will list all completed SARs, the action taken or intended to be taken in relation to the findings, or where Salford SAB decided not to implement a recommendation the reasons for that decision.


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