Helping agencies more effectively safeguard adults

Wiltshire’s Safeguarding Adults Board is required to commission Safeguarding Adult Reviews (SARs) when an adult with care or support needs dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked together more effectively to protect the adult.

The Care Act 2014 introduced SARs, which were previously known as Serious Case Reviews and carrying out these reviews is a statutory requirement for Safeguarding Adults Boards. SARs are carried out to establish learning and to identify what is helping and what is hindering effective safeguarding work rather than to identify blame.

It is not currently a statutory requirement to publish reports; however it is recognised good practice to demonstrate the level of transparency and accountability needed to enable lessons to be learned as widely and thoroughly as possible. This should ensure professionals are able to understand what happened and, crucially, what needs to change in order to reduce the risk of similar tragic events happening in the future.

The Board’s Safeguarding Adults Review Policy was published in 2019 and will be reviewed on an annual basis. 

When should a Safeguarding Adult Review take place?

Under the statutory requirements of the Care Act 2014 a Safeguarding Adults Board (SAB) must arrange a Review 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 (s.14.133).

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, the individual 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.

In all cases the adult must have needs for care and support, but does not have to have been in receipt of care and support services for a SAR to be considered.

A new Partnership Practice Review Group (PPRG) has been established to bring together existing review processes for both statutory and non-statutory reviews of cases involving adults and children, including Safeguarding Adult Reviews, Rapid Reviews and Child Safeguarding Practice Reviews for Children and Domestic Homicide Reviews.

This new partnership approach is intended to:

  • reduce duplication and use skills, knowledge and capacity more efficiently
  • Enable better sharing of learning across both adult and children’s safeguarding systems and workforce
  • Enable better oversight and management of reviews, actions and recommendations and demands on partner agencies through a centralised coordination process


The Terms of Reference set out more information about the PPRG. To make a referral into the group please use the Referral Form.

More information on SCRs and Child Safeguarding practice Reviews can be found here.

More information about local DHRs can be found here.

Local learning – Safeguarding Adult Reviews

Adult A – this review was published on 22 May 2018

Adult A – Learning briefing

Adult B – this review was published on 22 May 2018

Adult B – Learning briefing

Adult C – this review was published on 18 February 2019

Adult C – Learning Briefing

Adult D – this review was published on 3 December 2018

Adult E  this review was published on 6 June 2019

Adult H – Learning Briefing August 2020

Adult L – Learning Briefing July 2021

In line with the statutory guidance these reviews have been led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed.

The reviews have also been anonymised with regard to the adults at risk and to the agencies and professionals involved.  The purpose of these reviews is to ensure that professionals are able to learn from past experience and to improve local safeguarding practice. Anonymising these reports helps to ensure that:

  • The review process respects the privacy of family members
  • Professionals are able to engage in the review process in an open and transparent way

In March 2019, we published a Learning Review of the SARs above. The following key themes were identified

  • Application of the Mental Capacity Act 2005
  • Self-neglect
  • Effective application of safeguarding procedures
  • Effective assessment
  • Communication
  • Difficulty engaging with service users


National learning

In 2017/2018 Professor Michael Preston-Shoot examined 26 serious case reviews (commissioned before the Care Act 2014) and 11 safeguarding adult reviews commissioned after implementation of the Care Act. Professor Preston-Shoot work identifies common themes in those 37 reviews and provides important learning for Safeguarding Adult Boards and their members. Whilst each Safeguarding Adults Board will examine local cases, by focusing on a greater number and range of cases this review provides wider learning and valuable lessons for organisations across the South West.

This thematic review, undertaken by Professor Michael Preston-Shoot, forms part of the strategic priorities for 2017/18 set by South West regional adult safeguarding leads and South West ADASS. The thematic review undertook an analysis of the nature and content of 26 serious case reviews commissioned by Safeguarding Adults Boards in the South West region from 1st January 2013 up to the implementation of the Care Act 2014, and 11 safeguarding adult reviews commissioned and completed by Safeguarding Adults Boards in the South West region since implementation of the Care Act 2014 on 1st April 2015, up to 31st July 2017.

Thematic Review of Serious Case Reviews and Safeguarding Adult Reviews: A report for South West Region Safeguarding Adults Board

Presentation to SW ADASS Regional Safeguarding Conference

For more information please contact