Learning from Practice (Adults)

What is a Safeguarding Adult Review (SAR)?

A SAR is held when an adult at risk dies, or experiences serious neglect or abuse, and there is concern that partner agencies could have worked more effectively to protect them. Please replace with:

A Safeguarding Adult Review (SAR) is conducted when agencies believe there is valuable learning that can help to improve the way multiple agencies work together to safeguard an adult. This learning is used to consider different ways of working and to identify how we can improve frontline practice through training resources and better alignment of policies and practice designed to prevent harm.

The SAR process is not designed to apportion blame or to act as a complaints process; it is designed to promote a positive culture of reflection and learning across the MSP supporting agencies to work together towards positive outcomes for the adult and/or family involved.

SARs are commissioned when:

there is reasonable cause for concern about how MSP members or other agencies providing services, worked together to safeguard an adult; and
the adult has died, and the MSP 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); or
the adult is still alive, and the MSP knows or suspects that the adult has experienced serious abuse or neglect.

How is a SAR carried out?

Each SAR is written by an independent person who has specialist skills and knowledge. All the agencies involved contribute to the review and a group of senior managers make sure improvements are made. Information is collected by all agencies called an Individual Management Review (IMR). It includes a chronology, a review of recorded information and interviews with key people involved.

It is essential that adults and their families are made aware that a Safeguarding Adult Review is taking place and that they are offered the opportunity to contribute to the review process. Early discussions will be needed with the adult, family and carers or friends (identified as appropriate by the Review Panel) and they should be informed of concerns and that a SAR is underway.

The completed IMRs are given to the Adult Practice Review Panel (APRP) and the independent author, who uses them and any further inquiries they decide to make, to produce a draft report, including recommendations on actions or changes needed. To find out more about the Adult Practice Review Panel visit our ‘who we are’ page.

The finished report is approved by the APRP and then published on our website.

For further information on the screening process and the SAR criteria please download our SAR 7 minute briefing and SAR Practice Guide:

SAR Screening 7 minute briefing

For further guidance please read our Adult Practice Guidance and Toolkit

Learning from Reviews

The report is published and made available to the public on our website alongside learning resources to support the review. The report includes recommendations which are implemented through the Manchester Safeguarding Partnership. Information is shared through our bulletin, Adult Safeguarding Learning Forum and is often included in our multi-agency training.

SAR Referral Process

If an individual or agency feels a case should be referred for a SAR they should complete the MSP SAR Referral Form and partner agencies are asked to contribute any information they may have about the case. This is then screened by the Adult Practice Review Panel to determine if it meets the criteria.

If you have any queries please contact the MSP Business Unit.

COMPLETED FORMS SHOULD BE SENT TO THE MSP INBOX: manchestersafeguardingpartnership@manchester.gov.uk

Published SARs

Below is a list of SARs published by MSP. Click the link to download:

What is a Safeguarding Adult Review (SAR)?

How is a SAR carried out?

Learning from Reviews

SAR Referral Process

Published SARs

SAR Keith (Oct 2023)

SAR Gabriel Learning Resources (March 2023)

SAR Rayyan

SAR Gayle (June 2022)

Carer’s Thematic Review (Jan 2022)

Self Neglect Thematic Review

SAR Johnny (Feb 2021)

SAR Olia and Baby W (January 2021)

Adult AD (June 2020)

Homelessness Thematic Review (Published Aug 2020)