Safeguarding Adult Reviews

What is  a Safeguarding Adult Review ?

A Safeguarding Adults Review (SAR) is a Multi-Agency review process 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.  The purpose of a SAR is to promote effective learning and improvement, not to apportion blame.

All requests for a Safeguarding Adults Review should be made using our Safeguarding Adults Review Request form which you can download here: 

When is a SAR carried out?

A SAR is commissioned when there is reasonable cause for concern about how  SAB members or other agencies providing services, worked together to safeguard an adult if:

  • The adult has died, and 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)


  • The adult is still alive and SAB knows or suspects that the adult has experienced serious abuse or neglect.

Please view our SAR Policy Procedure here

Download the Sandwell SAB Review referral form here

If you require an electronic version to complete please contact

Completed forms should be returned securely to the:

SSAB Business Manager:


Safeguarding Adult Reviews

The Care Act 2014 (S44) introduced statutory Safeguarding Adult’s Reviews (previously known as Serious Case Reviews). This is one of the three core duties of a Safeguarding Adult’s Board (SAB). Local authorities are responsible for the establishment of SABs, and the Care Act 2014 specifies that there are three core members:

  • the local authority
  • the integrated care board
  • the police

The prime purpose of a Safeguarding Adult Review  (SAR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of adults with care and support needs.

A Safeguarding Adult’s Board must 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:

The Safeguarding Adult’s Board knows or suspects that an adult has died of abuse or neglect, or is alive, but has experienced serious abuse or neglect; and there is reasonable cause for concern about how members of the Safeguarding Adult’s Board, or other persons with relevant functions worked together to safeguard the adult.

Each member of the Safeguarding Adult’s Board must co-operate in and contribute to the carrying out of a review in order to:

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

(b) apply those lessons to future cases.

Safeguarding Adults Reviews will usually result in an Executive Summary being produced which will be published on this website.

Informal enquiries can be made to the Board Business Manager at


Recently Published SAR’s

Jeff – Deceased November 2020

Statement-from-Independent Chair-Sue-Redmond-Jeff

Jeff SAR learning overview report

Impact statement-Jeff

Learning brief-Jeff

Thematic SARs – Kim and Morgan

Kim – Deceased August 2020

Morgan – Deceased July 2020

Statement-from-Independent Chair-sue-redmond – Morgan and Kim-Final-PDF

Learning Brief – Kim-Final-pdf

Impact Statement from Family Member – Kim-Final-PDF

Learning Brief – Morgan-Final-PDF

Adeena – Deceased January 2019

Statement-from-Independent Chair-sue-redmond-adobe

Christine – Deceased June 2019

SAR Christine – SAR Statement – PDF

SAR Christine – Case Study PDF

SAR Christine Sandwell SAR PDF


Anne – Deceased May 2021

SAR SSAB Statement

SAR Anne

Case Study – Anne_

Anne overview report

Anne – Learning Brief

Anne – Executive Summary

Impact Statement – Anne


Published SARS

Betty  – Deceased March 2016

Sandwell-SAR-Betty v-Final-v2  


William – Deceased December 2016