Published SARs and other reviews

Please note that over time, the Health and Social Care context changes. This will need to be taken into consideration when reading SAR reports, particularly the older reports.

Joint Adults' and Children's Review (2023)

Mandatory SAR/CSPR

This review identified the following learning themes:

Cultural Awareness
Impact of Covid-19 pandemic
Professional response to neglect
Think Family – multi agency working
Professional Curiosity
Domestic Abuse
Equality Act (2010)
Voice of the family and their lived experience

Joint Adults' and Children's Review

Francis (2024)

Discretionary SAR

This review identified the following learning themes:

Exploitation
Drug addiction
Self-Neglect
Importance of timeliness in decision-making
Multi Agency Risk Management
Professional Curiosity

SAR Francis (2024)

Susan (2022)

Mandatory SAR/DHR

(Final approval was received by the Home Office in March 2024)

This review identified the following learning themes:

Domestic Abuse
Mental Health
Adverse Childhood Experiences (ACEs)
Cross-border working
Think Family

SAR/DHR Susan (2022)

Christopher (2023)

Mandatory SAR

This review identified the following learning themes:

Domestic abuse/Carer abuse
Mental Health
LGBTQ+
Bariatric Care
Strength based assessment
Making Safeguarding Personal
Multi-Agency Approach

Christopher

Stanley (2023)

Mandatory SAR

This review identified the following learning themes:

Continuity of care and care needs
Strength based assessment.
Making Safeguarding Personal
Nutrition and hydration
Assurance around standards of care
Capacity/Market Management
Working Together
Voice of the carer
Escalation pathways
Impact of Covid 19

Stanley

ET (2023)

Discretionary SAR

This review identified the following learning themes:

Capacity in the care market
Hospital Admission/Discharge
Therapeutic Support/Rehabilitation
Sexual Assault
Safeguarding – management S42 enquiries
Deprivation of Liberty (DOLS)
End of Life Care

Jayne (2022)

Mandatory SAR

This review identified the following learning themes:

Bariatric care and transport
Complex Needs
Discharge Planning
Multi Agency approach
Needs of the family/main care giver

Jayne

Irene (2022)

Mandatory SAR

This review identified the following learning themes:

Domestic abuse in older adults
Needs of the family/main care giver

Irene

Kannu (2021)

Mandatory SAR

This review identified the following learning themes:

Advocacy
Cultural Needs
Deprivation of Liberty Safeguards
Disability
Mental Capacity
Non-Concordance
Self-Neglect
Timely Multi-Agency Collaboration

Kannu

Mathew (2021)

Discretionary SAR

This review identified the following learning themes:

Care Act Statutory duties
Effect of Covid-19 pandemic
Escalation
Multi Agency Approach
Parenting/role of the father
Think Family Approach

Mathew

Peter (2021)

Mandatory SAR / Domestic Homicide Review

This review identified the following learning themes:

Alcohol Misuse
Coercion and Control
Domestic Abuse
Exploitation
Homicide
Housing
Mental Capacity
Mental Health
Self-Neglect

Peter

Patrick (2021)

Discretionary SAR

This review identified the following learning themes:

Homelessness
Substance misuse
Safeguarding Duty (Care Act 2014)
Recognising signs of Self-Neglect
Working Together

Patrick

Eric (2020)

Mandatory SAR

This SAR identified the following learning themes:

Mental Capacity
Mental Health
Needs of the family/main carer giver
Non-Concordance
Self-Neglect

Eric

Andy (2019)

Mandatory SAR

This SAR identified the following learning themes:

Complex Needs
Mental Capacity
Non-Concordance
Self-Neglect

Andy

SAR JW (2018)

Mandatory SAR

This review identified the following learning themes:

Carers
Complex Needs
Learning Disability
Mental Capacity

Mary (2018)

Learning Review

This review identified the following learning themes:

Carers
Domestic Abuse
Mental Capacity
Non-Concordance
Self-Neglect

Mary

Child / Adult 15 (2015)

Learning Review

This review identified the following learning themes:

Domestic abuse
Domestic servitude
Exploitation
Human trafficking
Modern slavery
Physical assault
Rape

Child / Adult 15

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