Safeguarding Adults Reviews

A Safeguarding Adult Review (SAR) is a statutory duty of the Telford and Wrekin Safeguarding Partnership (TWSP) under Section 44 of the Care Act 2014, and must be undertaken when:

An adult or adults with care and support needs die as a result of abuse or neglect and there is a concern that partnership agencies could have worked more effectively to protect the adult(s); OR
An adult or adults with care and support needs has not died, but the TWSP knows or suspects that the adult has experienced serious abuse or neglect with a concern that partnership agencies could have worked more effectively to protect the adult. SARs are not enquiries into how an adult died and who is responsible. That is a matter for the Coroner or criminal courts.

The purpose of a SAR is to:

Learn from cases where agencies could have worked together more effectively;
Consider whether serious harm could or could not have been predicted or prevented, and develop learning that enables the partnership to improve its services, and prevent abuse and neglect in the future; • Identify any issues in multi or single agency policies and procedures;
Agree on how the learning will be acted on, and what is expected to change; and
Publish a summary report, which is available to the public. SARs help to improve services, multi-agency working, share best practice and lessons learnt, and to better safeguard adults from risk of abuse and neglect.

What happens when I refer a case for a SAR?

Information will be requested from agencies known to be or have been involved in the case, as part of the initial scoping exercise;
The SAR Review Panel will meet to discuss the referral, and consider whether the case meets the SAR criteria;
The SAR Review Panel will make a recommendation to the TWSP Independent Chair;
Where the criteria is met, the individual or organisation that requested the SAR will be notified and engage in the proceedings of the review. Families will also be invited to contribute to the review; and • If the criteria is not met, the individual or organisation will be notified, and the SAR Review Panel will ensure that any learning from the scoping exercise is retained by TWSP for future improvement. Equally where the criteria is not met the SAR Review Panel may still recommend to the TWSP Independent Chair that a learning exercise or discretionary SAR be undertaken, dependant on the case circumstances.

Key documents:

Data and Statistics:

NHS Digital - a complete set of data dashboards including the Safeguarding Adults Collection (SAC) data
Joint Strategic Needs Assessment (JSNA) - an assessment of the current and future health and social care needs of the people in Telford and Wrekin.

Safeguarding Adult Reviews (SARs) exist to help organisations learn from serious incidents and prevent future harm. However, we recognise that behind every review is an individual, their family, and a wider community who have already experienced significant distress. Publishing SARs can be particularly sensitive in the period immediately following a traumatic event, but the potential impact does not end there — deeply personal information can continue to affect those involved for years afterwards.

Under Article 8 of the Human Rights Act, every person has the right to respect for their private and family life. Even when SARs are anonymised, they can still include highly personal details about adults at risk, their relatives, and others connected to the case. Keeping such information permanently available online may unintentionally prolong distress or make it easier for future generations to encounter painful material they were not prepared for.

Some areas already demonstrate a thoughtful and proportionate approach. For example, Preston Community Safety Partnership publishes its statutory reviews for 12 months before removing them from public websites, while still providing access on request. This model protects families and honours dignity while ensuring that professional learning remains available.

We believe a similar approach for SARs offers the right balance.

By publishing SARs for one year and then removing them from public view, we can:

Share essential learning to improve safeguarding practice,
Reduce long‑term distress for families and those connected to the review,
Protect individuals — including future generations — from unnecessary exposure to sensitive information, and
Uphold the dignity and privacy of those affected.

Reports would still be accessible on request, ensuring that learning is preserved while treating adults and their families with the compassion and respect they deserve.

Our published SARs

Safeguarding Adults Reviews – themes and implications from a national analysis: in discussion with Professor Michael Preston-Shoot

In this ‘in conversation’ Alex Ruck-Keene talks to Professor Michael Preston-Shoot about the second national analysis of safeguarding adults reviews he recently led with Professor Suzy Braye. They talk about the background and context, and Michael draws out some of the key themes, before they conclude with asking whether SARs actually achieve anything.

Watch the recording with Professor Michael Preston-Shoot.

The three reports coming from the analysis can be found here:

Stage 1: Case characteristics; nature of the abuse and neglect; SAR reviewing process

Stage 2: Analysis of learning

Stage 3: Conclusions and improvement priorities

The Safe Care at Home Review Michael talks about can be found using this link.

Advocacy support

Are you, or do you know someone who, because of disability, illness, social exclusion and other challenges, find it difficult to express their views or get the support they need?

Did you know there are people that can help?

Visit the POhWER website to find out more and make contact!