Sussex Safeguarding Adults Review Protocol

Version: 5
Date published: October 2026
Review due: September 2029

With thanks to Surrey Safeguarding Adults Board, on whose work this Protocol is built.

Introduction

The Care Act 2014 places a statutory duty on Safeguarding Adults Boards (SABs) to undertake Safeguarding Adults Reviews (SARs).

This protocol has been developed by the Brighton & Hove, East Sussex, and West Sussex SABs to support the identification of, and response to, SARs across Sussex, and to ensure that the SABs are discharging their statutory duty. The protocol is part of the Sussex Safeguarding Adults Policy and Procedures.

The protocol aims to ensure that there is a consistent approach to the process and practice in undertaking SARs across Sussex that follows both statutory guidance and local policies. The protocol will help in deciding when to make a referral for consideration as a SAR. It is important that referrers consider the SAR Referrals Briefing Note at Appendix C, which details the circumstances in which a SAR referral should be made.

Statutory guidance

The Care and support statutory guidance | Gov.UK states the following:

• SABs must arrange a SAR when an adult in its area 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 adult.
• SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. In the context of SARs, something can be considered serious abuse or neglect where, for example, they would have been likely to have died but for an intervention or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect. SABs have the discretion to conduct a SAR in any other situations involving an adult in its area with needs for care and support.

Please refer to the section on Out of Area Safeguarding Adult Reviews for circumstances in which it may be more appropriate for the authority of ordinary residence to consider the SAR referral.

The SAB should be primarily concerned with deciding what type of review process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again. This may be where a person’s story (or their experiences) can provide useful insights into the way organisations are working together to prevent and reduce the abuse and neglect of adults. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future scenarios. For further information on the types of review please see the section on SAR methodology.

Purpose of a SAR

The purpose of a SAR is to determine what the relevant agencies involved in supporting the person might have done differently to identify and address risk in order to minimise harm. It is not to enquire into how a person died nor is it to apportion blame. It is to learn from situations, and to ensure that learning is applied to future people’s experiences to minimise the risk of similar harm occurring again.

A SAR is to explore whole system/multi-agency learning; where there were missed opportunities that relate to one agency alternative processes should be considered.

Other processes exist to hold organisations to account or identify how a person died, including criminal and coronial proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as those regulated by the Care Quality Commission, the Nursing and Midwifery Council, Social Work England, and the General Medical Council.

A SAR will ordinarily be considered following the conclusion of complaint and statutory processes (e.g., coronial inquest, police criminal investigation, Section 42 safeguarding enquiry) and non-statutory enquiries/reviews (e.g., serious incident or patient safety review, LeDeR, or substance related death reviews). However, on occasion there may be situations where enquiries or investigations have not been completed, but the circumstances necessitate that a SAR should commence in parallel to the other investigatory process. Decisions as to the need for and the appropriateness of this will be made on a case-by-case basis.

The purpose of conducting a SAR is to:

• Minimise the risk of future deaths or serious harm.
• Establish whether there are lessons to be learnt from the circumstances of the person’s experiences about, for example, the way in which local professionals and agencies work together to safeguard adults at risk.
• Analyse the effectiveness of procedures and their application (both multi-agency and those of organisations).
• Identify systems learning and make recommendations for future action to reduce the likelihood of similar harm occurring again.

It is acknowledged that agencies will have their own internal and/or statutory review procedures to investigate serious incidents. SARs are not intended to duplicate or replace these.

Information about criminal investigatory proceedings can be found in section 2.4 of the Sussex Safeguarding Adults Policy and Procedures.

Criteria for a Safeguarding Adults Review

A SAR should always be considered if:

• an adult with care and support needs has died, and the 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); or
• an adult has experienced serious abuse or neglect which has resulted in permanent harm, reduced capacity, or quality of life (whether or not it knew because of physical or psychological effects), or the individual would have been likely to have died but for an intervention; and
• there is concern that partner agencies could have worked more effectively to protect the adult.

A SAB may also arrange for a SAR in any other situation which involves an adult, in its area, with needs for care and support.

Under section 44 (4) of the Care Act a discretionary review can be undertaken in situations where this duty is not met, but it is considered there are learning opportunities that will reduce the likelihood of something similar occurring in the future or it is in the public interest.

This may be as part of a joint approach in partnership with Safeguarding Children Partnerships or Community Safety Partnerships where the person is a recent care leaver, had special educational needs, or where the eligibility criteria for a Domestic Abuse Related Death Review is also met.

Out of Area Safeguarding Adult Reviews

SABs will normally only consider an adult’s experiences where the person who died or has come to harm was/is ordinarily resident within their local authority area, as per the Care Act. In practice this means each SAR subgroup will normally be considered for an adult who was, or is, resident within their area at the time of their death or serious incident of harm.

However, referrals may be considered for adults whose circumstances span more than one local authority area or region and where an adult has moved across geographical boundaries, either on a temporary or permanent basis, or the location of the abuse or neglect is different to that of where the adult is ordinarily resident.

In these situations, there is a need for collaboration and co-ordination between SABs to ensure statutory duties are met, learning is captured effectively, and families experience a consistent and respectful process. The South-East Region SAB network (which includes all three Sussex SABs) have produced guidance to support a best practice approach in this area, outlining the process for SARs where this is the case:

• South East region framework for cross-boundary Safeguarding Adults Reviews (PDF, 232KB)

Where a person placed by either the Integrated Care Board (ICB), or by one of the three local authorities, in another area be the subject of circumstances that would necessitate a SAR, then it would be for the SAB of the locality that placed the person to oversee and carry out a SAR.

Should the person not be an ordinary resident within the relevant local authority area, but an investigation or enquiry has been carried out by a Sussex agency (e.g. Sussex Police, NHS Surrey and Sussex, or one of the local authorities) because the safeguarding incident has occurred within Sussex, then the relevant SAB will consider where the person was or is ordinarily resident and proceed from there in line with the principles of the cross-boundary guidance.

Boards and organisations should co-operate across borders, and requests for the provision of information should be responded to as a priority.

The National Network for Safeguarding Adults Board have also produced essential guidance for undertaking Safeguarding Adult Reviews that includes information on cross-border working:

• Approved essential guide to Safeguarding Adult Reviews (PDF, 5.2MB)

SAR operating framework and governance

A SAB is the only body that can undertake a SAR. SARs and discretionary reviews under section 44 (4) of the Care Act are overseen by the SAB, which is responsible for ensuring that effective systems are in place for the completion of these including:

• decision making in respect of undertaking reviews,
• formally accepting reports, and
• agreeing sign-off of the report for publication.

Responsibility for the management of SARs is delegated to the SAR subgroups. The membership of these subgroups includes the statutory members of the SAB (the Local Authority, Sussex Police and NHS Surrey and Sussex ICB), with Terms of Reference which are reviewed on a regular basis.

The SAR subgroups meet on a planned basis throughout the year to consider SAR referrals, decide on next steps and to co-ordinate SARs in progress.

Staff directly involved in the care and support of individuals subject to a SAR should be notified of the decision to undertake a SAR, and there is an expectation that support will be provided to them by their agency including support for consideration of vicarious trauma.

Involved organisations will be provided with copies of reports for comments on factual accuracy prior to the final draft. Where a SAR Panel is established, depending on the methodology being used, it will be the role of the Panel to ensure the report is factually accurate and based on the evidence gathered during the process.

All involved agencies will be asked to participate in identifying solutions to any recommendations of the review to support improvements in practice.

The Brighton & Hove, East Sussex, and West Sussex SABs are committed to working together, where appropriate, to ensure a proportionate and efficient approach to the undertaking of SARs. This may include undertaking thematic reviews across areas where similar issues have been identified or building on relevant existing learning from a SAR in another area.

See Appendix A for an overview of the SAR governance and process.

Submitting a SAR referral

Any member of the public, professional, or agency can make a referral for a SAR, in any situation where the criteria are met.

Members of the public should discuss with a professional or agency involved who will support to consider if the SAR process could be appropriate. If it is considered appropriate, the professional or agency should complete and forward a referral to the relevant SAB. If there is no professional or agency involved, contact should be made with the relevant SAB Support team (see below) who will discuss and complete a referral form if appropriate.

Professionals and agencies should refer to the SAR Referrals Briefing Note for guidance on relevant considerations and to ensure all steps required are followed (see Appendix C).

Professionals and agencies should discuss making a referral with their senior manager or organisation’s safeguarding lead prior to submitting the referral and consider contacting the SAB’s Support Team to discuss. Referrals should be submitted using the referral form at Appendix B.

Referrals must be submitted to the relevant SAB:

• Brighton & Hove SAB – SafeguardingReviews@brighton-hove.gov.uk
• East Sussex SAB – SafeguardingReviews@eastsussex.gov.uk
• West Sussex SAB – safeguardingadultsboard@westsussex.gov.uk or phone 03302 227952

As the referral will contain confidential information, it should be sent by secure email or be password-protected, with the password emailed separately.

Deciding to undertake a SAR

When a SAR referral is received it will be triaged to consider whether all the necessary information has been provided. This may include contact with the referrer, as well as with other agencies listed on the referral form, to gather further information and their views regarding whether the SAR eligibility criteria may be met. Where possible, the referral will be scheduled for consideration at the next SAR subgroup meeting.

In line with Making Safeguarding Personal the SAR subgroup should consider the involvement of the person, family, or carers from the outset of the referral. Wherever possible the person, family, or carers should be advised of the referral. However, it is recognised that this may not always be appropriate, for example if contact may pose a risk. These discussions and decisions should be clearly recorded in the SAR subgroup minutes and on the SAR referral form.

Where SAR referrals are submitted inappropriately in place of a safeguarding concern or complaint, the referrer will be signposted to the relevant pathway and informed that the SAR referral will be considered for closure or non-progression at the next SAR subgroup meeting.

When SAR referrals are discussed at the SAR subgroup, there is the opportunity for referring agencies to attend the meeting to present their referral.

The SAR subgroup may consider that further information is required from agencies involved in providing care and support to the person before a recommendation can be made to the Independent Chair. This may involve requesting each agency complete a summary of information (SOI) form and/or an Individual Management Review (IMR) to provide further detail of their involvement. Information received will be considered by the SAR subgroup before a recommendation is then made to the Independent Chair as to whether the criteria is met.

The Chair of the SAR subgroup is responsible for deciding on the recommended outcome of the referral, based on the proposals made by the SAR subgroup. When deciding on the outcome a holistic, pan-Sussex review of SARs previously undertaken will be included to ensure the most proportionate approach is adopted. If necessary, legal advice will be sought on a case-by-case basis. The recommendations are then forwarded to the Independent Chair of the SAB for endorsement.

If the criteria for a statutory review is not met, as endorsed by the Independent Chair, the SAR referral will be closed. Ordinarily, there will be no further action for the SAB. However, if it is considered that an action may be needed by the SAB, this will be taken forward outside of the SAR Protocol.

In the absence of the Independent Chair, the endorsement of the SAR Chair’s recommendation for the outcome of a SAR referral, will be based on the views of the three statutory partners.

If there is a difference of opinion on the recommended outcome between the SAR Chair and the SAB Independent Chair which cannot be resolved, then the Director of Adult Social Services (DASS) will be involved to agree a way forward and reach a decision.

The referrer will be informed of the SAR Subgroup decision and where the person, family, or carers have been informed, referrers will be requested to feedback to them.

If the decision is made to undertake a SAR, the SAB will make arrangements to notify partner agencies of the Board and the Care Quality Commission (regulator of health and social care services) if registered services are involved.

Making Safeguarding Personal

It is important that consideration is given at an early stage to the most appropriate means of engaging with and involving the person, their family, and/or carers within the SAR process, where this is appropriate. If appropriate, contact will be made with all involved family members in the first instance to understand their desired level of involvement. This will be followed with written confirmation detailing with whom, and how frequently, ongoing contact will be maintained.

The person(s) will be notified that the review will look at records and notes of all agencies involved including where relevant, public bodies such as adult social care and health providers. Consent will be requested but is not required for a SAR to go ahead. Those involved will be provided with a copy of the ‘SAR guide for families, friends, and carers’ (see Appendix D).

Where appropriate, the SAB will make arrangements for the person and/or their family, or carers to participate in the SAR. Meetings may take place during the review with the SAR referrer to gain views and feedback from the person and/or their family or carers. The person and/or their family and carers participating in the SAR will be kept updated at key stages of the review and notified of the publication of the report.

SAR methodology

The Care and Support Statutory Guidance states that SABs must identify the most appropriate review that will promote effective learning and encourage action to be taken that will prevent similar incidents happening again.

SARs can be conducted in a variety of ways and no one model will be applicable for all situations. The SAR subgroup will endorse the approach best suited and proportionate to the circumstances and context, including the use of key lines of enquiry (KLOE) to assess learning from previous reviews. Models include:

• Traditional SAR approach (Individual Management Reviews may be used as part of this methodology to request individual and organisational analysis from agencies involved)
• Thematic Review
• Joint review (for example together with a Safeguarding Children Partnership or Domestic Abuse Related Death Review)
• Systems Analysis
• Learning Together
• Significant Incident Learning Process
• Significant Event Analysis or Rapid Review
• Appreciative Enquiry

The Care and Support statutory guidance advises that whatever methodology is adopted the following elements should feature:

• SAR subgroup overseeing process
• Terms of Reference
• Involvement of relevant professionals, in terms of providing reports, attending SAR Panel meetings, learning or practitioner events
• Agreed engagement or involvement with the person and/or their family
• Final report with recommendations or questions for the Board to consider

The decision on the methodology must also take into consideration the cost, resources and length of time required to conduct the review.

Timescales

SARs must be completed in a timely manner and once the decision to undertake a SAR has been made, it is good practice for it to be completed within a nine-twelve month time period.

It is acknowledged that where there are dual processes or reviews that are complex, these may require more time. Any urgent issues which emerge from the review and need to be considered without delay should be brought to the attention of the SAB.

The SAR report

The SAR report should:

• Include sound analysis of what happened based on evidence, factual accuracy, the recognition of good practice, and improvements already made or in progress.
• Include findings or recommendations which are evidence-based, focus on systems learning, and are SMART (specific, measurable, achievable, realistic, timely).
• Be written concisely, in plain English, and using a trauma-informed approach.

Where possible, the report and its findings will be shared with the person, and/or their family and carers.

Where possible and practicable, the person(s) and/or their family or carers will be consulted with to agree how the person(s) in the review will be referred to.

The final report will be signed off by the SAB.

Publication and media

The SAR Subgroup Chair, in consultation with the SAB Independent Chair, will consider appropriate publication of the report on a case-by-case basis. Discussions about publication will be held with the person(s), their family or carers (where possible).

Any media and communication concerns will usually be co-ordinated by the relevant council’s communications team. This will be done in collaboration with the communications teams of the other agencies involved, alongside agreed representatives of the Board.

To support wider learning all SARs and discretionary reviews will be considered for publication on the website of the relevant SAB, as well as the Sussex Safeguarding Adults Policy and Procedures website to support wider learning. This will include consideration of any learning identified for other Sussex SABs that needs to be adopted locally or and may involve a written response for this. In some cases, an executive summary may be published to maintain confidentiality and/or promote learning. Where publication takes place, the Independent Chair of the SAB will release a statement where appropriate.

It may be necessary to delay the publishing of reports in some circumstances, for example, pending the conclusion of a criminal investigation. However, individual agencies can progress with implementing the learning from the review.

Implementation and evaluation

The real value of a SAR is the identification of learning to be taken forward to ensure professional multi-agency safeguarding is improved and the risk of a similar situation happening again is minimised.

The SAR subgroup will consider the recommendations from the report and agree an action plan (if required).

The SAR subgroup will be responsible for ensuring the implementation of the action plan, monitoring the progress made, and making links with relevant subgroups of the Board to take forward assurance and learning.

Following the completion of a SAR, learning resources (e.g., a learning briefing, video, podcast) will be produced to highlight key themes so agencies can consider the learning required and what actions need to be taken to embed this and improve practice.

In line with Making Safeguarding Personal, and as appropriate, feedback will be sought from the person, their family or carers. Feedback may also be sought from agencies involved and the reviewer to develop and improve SAR practice and processes. Each SAB will use their own feedback form for this stage of the process.

Following completion of SAR action plans, which are based on delivering on the recommendations made, assurance will be sought from relevant agencies that learning is embedded. Assurance processes may include quality assurance processes such as surveys, audits, or self-assessments.

Review

There will be a formal three-yearly review of this protocol to take account of developments and new legislative requirements.