Safeguarding adults reviews
Overview
A safeguarding adult review (SAR) is carried out when an adult dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the person at risk.
A SAR may also be conducted when a person has not died but it is known or suspected that they have experienced serious abuse or neglect, sustained a potentially life threatening injury, serious sexual abuse or serious or permanent impairment of health or development.
All relevant board agencies should contribute to the review, sharing information and implementing and disseminating the lessons learnt.
The SAR brings together and analyses the findings from individual agencies involved, in order to make recommendations for future practice where this is necessary and also highlights good practice.
Safeguarding adults review subgroup
Derby Safeguarding Adults Board (DSAB) has a SAR subgroup which meets quarterly to discuss and make decisions regarding new referrals, whilst the Quality Assurance Subgroup oversees current reviews and ensuring learning is implemented from Derby reviews into multi-agency practice. The QA subgroup also monitors reviews from other safeguarding adults boards to ensure any relevant learning for Derby is distributed.
The QA subgroup is also responsible for overseeing the implementation of recommendations and providing assurance to the Board that this has been achieved.
Learning from multi agency reviews
Multi agency learning reviews take place where the criteria set in the Care Act for a safeguarding adult review to be undertaken is not met, but where it is felt that there may be valuable learning for a number of organisations about the way in which they work together to safeguard adults with care and support needs.
Derby SAR04 "Dylan"
Statement for SAR04
As the Independent Chair of Derby City Safeguarding Adults (DSAB) and on behalf of all DSAB members we would like to express our sincere condolences to the family of Dylan and thank them for their contribution to the learning from this case.
Dylan, who suffered from multiple sclerosis and chronic obstructive pulmonary disease,was supported for his care and support needs by day care centre staff. Tragically Dylan died at home following a fire at his home. DSAB decided to conduct a Safeguarding Adults Review following his death with the process involving a review of all partner agencies actions to identify learning from the case to inform and improve future practice.
The learning review has now been published on the DSAB website. The review identified several areas of good practice including proactive safeguarding action taken by East Midlands Ambulance Service to alert the Fire Service following a call to Dylans home after noticing burn marks on his clothing and carpets, together with the care provider securing support from Speech and Language therapists to ensure Dylan’s needs were prioritised.
The learning review also identified several recommendations for improvement including partners exploring a fire risk flagging process to help assess the risk of fire in the home and developing a practitioner toolkit to support inclusive engagement.
Where a learning review identifies recommendations for improvement DSAB will seek assurance that agencies have embedded the learning from the case.
Richard Proctor, Independent Chair, Derby Safeguarding Adults Board.
Learning Brief and LOOP
Derby SAR03 ‘Pink’.
Statement for SAR03
As the Independent Chair of Derby Safeguarding Adults Board (DSAB) and on behalf of all DSAB members we would wish to express our sincere condolences to the family of Pink and thank them for their contribution to the learning from this case.
Pink was considered by multiple agencies who provided her with care and support to have profound multiple learning disabilities. DSAB decided to conduct a Safeguarding Adults Review following her death with the process involving a review of all partner agencies actions to identify learning from the case to inform and improve future practice.
The learning review has now been published on the DSAB website. The review identified several areas of good practice including conducting multidisciplinary team meetings to review Pinks case and the use of speech and language therapists to attempt to engage Pink whilst at home.
The learning review also identified a number of recommendations for improvement including responses to Pinks views wishes and preferences together with limited multi agency identification and management of risk and escalation.
Where a learning review identifies recommendations for improvement DSAB will seek assurance that agencies have embedded the learning from the case.
Richard Proctor, Independent Chair, Derby Safeguarding Adults Board.
Learning Brief and LOOP
Historic Completed SARs
Derby SAR01 "Samantha
DerbySAR01 "Samantha" was signed off by the Derby Safeguarding Adults Board in May 2021. Please see the findings from the case on the below attached Executive Summary report.
Derby SAR02 "Doreen"
DerbySAR02 "Doreen" was signed off by the Derby Safeguarding Adults Board in July 2023. Please see the findings from the case on the below attached Learning Brief.
Useful documents
- East Midlands Cross Boundary Safeguarding Adult Reviews Guidance for Business Units (v3.0 2026 March)
- SAR01 - Executive Summary Report
- Derby Safeguarding Adults Review Criteria Document and when to consider a SAR Referral
- SAR Information for Family, Friends and Carers
- Derby SAB SAR Protocol v.3
- Derby Safeguarding Adults Review Referral Form
- National Safeguarding Adults Board Guidance on the interface between safeguarding adult reviews and coronial processes
These documents are not fully accessible. If you need any in an accessible format, please contact [email protected].