Safeguarding Adult Reviews – resources for practitioners

The aim of a Safeguarding Adults Review (SAR) is to carry out a multi-agency review which seeks to determine what relevant agencies and individuals involved could have done differently that could have prevented harm or a death from taking place.

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.

Until April 2014 the MSAB carried out serious case reviews – with the implementation of the Care Act 2014 these became known as Safeguarding Adults Reviews (SAR) and worked slightly differently.

When and why do Safeguarding Adult Reviews take place?

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.

The purpose of a SAR is not to apportion blame. It is to promote effective learning and improvement to prevent future deaths or serious harm occurring again, and for agencies to work together towards positive outcomes for the adult and/or family involved.

Further information can be found in the Care and Support Statutory Guidance

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 2021  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 (APRP) to determine if it meets the criteria.

We have published a 7 minute briefing to explain the SAR referral process.

If you become aware of an incident or case:

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


Carrying out Safeguarding Adult Reviews

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.

The SAR Panel drafts a terms of reference for each SAR; and a Case Panel is formed, led by an independent author.

Each agency involved in the case, including any independent providers, arranges for an Individual Management Review (IMR) to be carried out by a manager independent of the case.

The IMR looks at the involvement and actions of the agency in the case. It has to cover the requirements of the terms of reference and be based on a set format which includes: a chronology, a review of recorded information and interviews with the key people involved. An IMR writer can be a suitably skilled and experienced manager from the agency, or an independent person commissioned by the individual agency.

The completed IMRs are given to the SAR Panel 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.

The draft report is presented to the SAR Panel, who reviews the report and recommended actions. These are then presented to the full Board for members to consider and agree the proposed actions needed.

The MSP then monitors the implementation of these actions with the help of the SAR Panel. The report is published and made available to the public via this website.

We have published a 7 minute briefing to explain the SAR process.

Published Safeguarding Adult Reviews

The MSP believes that findings from Safeguarding Adults Reviews should be shared as widely as possible in order to enhance learning and inform practice.

Reviews are published on this website as they are completed. Each SAR published is about a real person and our thanks go to the families who contribute to the reviews, as do our sincere condolences.

The MSP will publish all Safeguarding Adult Reviews (SAR) online for at least twelve months.

Current SAR publications:

All media enquiries relating to the publication of SARs should go to the MSP Business Unit in the first instance on by email to:

SAR Learning Packs – resources for practitioners

Learning packs for completed SARs are made available on the website as soon as practicable. These can be used by individual agencies for internal cascading within their organisation to make sure that the valuable lessons learned are shared across staff teams.

Supporting learning events will be advertised on the  MSP Training website.

Carers Thematic Review:

Adult AD 7 minute briefing: Published 9th June 2020

SAR Olia  – learning resources

SAR Johnny -learning resources

Self Neglect Thematic Review – learning resources

See our useful resource which includes the Self Neglect and Hoarding Strategy & Toolkit, plus resources from our self neglect learning conference:

Homeless Thematic Review – learning resources

Adult AA SAR: Learning event held 8th November 2017; full report published on 14.12.2017

Adult CA SAR: Learning event held 8th November 2017; full report published on 2.3.2018

Adult AB SAR: Learning event held 18th May 2018; full report published on 15.5.2018

Published Safeguarding Adult Reviews from other LSABs

Winterbourne View
South Gloucestershire’s Safeguarding Adults Board (SAB) commissioned a Serious Case Review following reports of patient abuse at Winterbourne Private Hospital in September 2012.

The review was commissioned by the SAB following the disclosure last year of the abuse of adults with learning disabilities and autism at the 24-bed private hospital owned and operated by Castlebeck Ltd.

Prepared by independent adult safeguarding expert Margaret Flynn, the review shows that the abuse at Winterbourne View Hospital resulted from serious and sustained failings in the management procedures of Castlebeck Limited.

It also identifies where other organisations’ systems and procedures fell short in commissioning patient care, and in reviewing and safeguarding the wellbeing of patients before and during their stay at Winterbourne View hospital.

Recommendations include a call for greater investment in community-based care in order to reduce the need for in-patient admissions at assessment, treatment and rehabilitation units such as Winterbourne View Hospital.

The report highlights the need for outcome-based commissioning for hospitals detaining people with learning disabilities and autism and says that the use of ‘t-supine restraint’ — in which patients are laid on the ground with staff using their body weight to restrain them – should be discontinued at such units.

The report also calls for notifications of concern, including safeguarding alerts, hospital admissions and police attendances, to be better co-ordinated and shared amongst safeguarding organisations to allow earlier identification of potential problems and earlier action to be taken.

Copies of the report can be found at

SAR resources for reviewers and practitioners involved in the SAR process

The MSAB SAR procedures (Dec 2017) have been developed to support reviewers, practitioners and support staff involved in the SAR process.

The Information sheet on Practitioner Learning Events (June 2017)  can be given to practitioners asked to attend a learning event.

We have published a 7 minute briefing to explain the SAR process.

SAR resources for families

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.

Information for families about the SAR process can be found on the MSAB SAR information for families (Dec 2017)

Key downloads on this page:


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