Safeguarding adults reviews

A safeguarding adults review (SAR) is a multi-agency learning process. It aims to identify and promote good practice, effective learning and recommendations for future practice so that deaths or serious harm can be prevented from happening again.

Its purpose is not to investigate how a death or serious incident happened or to hold any individual or organisation to account. Other processes exist for that, including: coroner’s and criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council.


The City and Hackney Safeguarding Adults Board must arrange a SAR:

  • when an adult in its areas 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
  • if an adult in its area has not died, but the board knows or suspects that the adult has experienced serious abuse or neglect – eg the individual would have been likely to die 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 any other situations involving an adult in its area with needs for care and support

Make a SAR referral

Any individual (member of the public or professional) or agency, may refer a case using the referral form below. Please read the guidance before making a referral.

John SAR, March 2023

See John SAR report (google doc)
See John SAR 7 minute briefing (google doc)

Daniel SAR, November 2022

See Daniel SAR report (google doc)
See Daniel SAR 7 minute briefing (google doc)

Philip SAR, September 2022

Mr EF SAR, March 2021

MS SAR, January 2021

Jo-Jo SAR, June 2019

Ms F SAR, January 2019

Yi SAR, November 2018

Ms Q SAR, March 2018

Mrs A and Mr B SAR, December 2016

Mr GH SAR, December 2016

Mrs Y SAR, December 2016

Mr BC SAR, April 2016

Page updated on: 16 August 2023