What is a Safeguarding Adults Review

When an adult who needs care and support either dies or suffers serious harm, and when abuse or neglect is thought to have been a factor, Birmingham Safeguarding Adults Board (BSAB) may need to review what has happened. This is called a Safeguarding Adults Review or SAR for short.

A SAR is a multi-agency review carried out to determine what agencies involved could have done differently that could have prevented harm or death from taking place.

The aim is not to apportion blame - it is to promote effective learning and improvement to prevent future death or harm occurring and to improve how agencies work together towards achieving positive outcomes for adults and their families.


When should a SAR take place?

SARs are commissioned when the following criteria has been met:

  • There is reasonable cause for concern about how BSAB members or other agencies providing services, worked together to safeguard an adult who needs care and support; and
  • The adult has died, and BSAB 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 BSAB knows or suspects that the adult has experienced serious abuse or neglect.

Sometimes BSAB may also arrange for a SAR to take place in other situations where they feel lessons need to be learnt.

What difference do SARs make to safeguarding?

  • SAR recommendations are used to agree an action plan for making changes or improvements to services to reduce the risk of future harm.
  • Action plans are agreed and monitored to make improvements.
  • Learning from the review is usually shared with BSAB partners via the website and through learning events.

What to do if you feel a case may meet the criteria?

  • Individual or agency should complete the BSAB SAR Referral Form including information they may have about the case.
  • email SAR referral form to: SCR.secure@birmingham.gov.uk
  • following receipt, the referral form is screened by the SAR subgroup against SAR criteria and the recommendation is made to the BSAB Independent Chair as to whether a SAR should take place.

How are SARs carried out?

  • There are different ways in which a SAR can be done. The SAR sub-group will decide on what type of review will promote effective learning and improvements to prevent future death or serious harm. Each SAR will involve gathering as much information as possible from as many sources as possible.
  • An independent person who has no involvement in the case will be asked to lead on the review and report back to the SAR sub-group.
  • Depending on the method used to carry out the review; agencies involved may be asked to contribute by providing chronologies of their involvement and by taking part in a series of multi-agency meetings, where the views and experiences of practitioners are sought.
  • The BSAB wants families and carers to be involved in the process as much as possible. They believe families, carers and where appropriate, the person who suffered harm should have the opportunity to discuss any concerns they may have and to share their thoughts and opinions.
  • The independent person will be asked to provide the SAR sub-group with any lessons learnt and any improvement that may be required.
  • The SAR sub-group will finalise the recommendation and develop an improvement plan on behalf of the BSAB and then will monitor the improvement plan over a period of time.
  • There may be a report that is published on the BSAB website, however, no individuals are named in it and no information is included that could lead to the people involved being identified.