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.

Statement for SAR01

Derby Safeguarding Adults Board (DSAB) commissioned a Safeguarding Adult Review (SAR) in 2019 concerning a Derby citizen we refer to as Samantha.

The Board asked related agencies to work together to consider what led to the circumstances faced by Samantha and the potential learning that could be taken forward as a partnership.

In addition to the comprehensive report included in the review, an Executive Summary Report has also been written to outline the background and findings explored.

The Executive Summary Report will be used as a tool to understand cases of a similar nature and prompt discussion amongst practitioners. The Executive Summary Report is now published on the Derby Safeguarding Adults Board.

The review process will not end with the publication of the Executive Summary Report and the Board will continue to oversee progress in relation to the recommendations of the SAR.

I want to reassure Derby citizens that as the Independent Chair of the Board, I will be ensuring that we learn from this experience and take forward all findings in a productive way.

I thank all those involved in the SAR process, especially the Independent Author who sought further understanding of Samantha’s journey to help us continually improve our chances of preventing abuse of vulnerable individuals in the future.

Allan Breeton, Independent Chair, Derby Safeguarding Adults Board

Statement for SAR02

Members of Derby Safeguarding Adults Board (DSAB) send their sincere condolences to the family of Doreen.

As a number of partner agencies were involved in Doreen’s care at home in the final months of her life, DSAB carried out a Safeguarding Adults Review following the inquest. This included a review to identify what all partner agencies can learn from this case.

The learning review has now been published on the DSAB website. It found that agencies worked well together in many areas to co-ordinate Doreen’s care, by making several referrals for safeguarding through the multi-agency hub, referring Doreen to a befriending service, and providing a Carelink alarm and a responder if needed.

It has also made a number of recommendations, including improvements in communications with partner agencies when a patient is being discharged from a hospital or residential care setting, and an assurance that safety plans are in place for all adults with care and support needs who are living at home.

Where a learning review identifies the need for improvements, there is an expectation that partner agencies will respond appropriately. DSAB will seek assurances that this has been done.

Allan Breeton, Independent Chair, Derby Safeguarding Adults Board

Useful documents

These documents are not fully accessible. If you need any in an accessible format, please contact DSAB@derby.gov.uk.‌‌‌