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A Safeguarding Adults Review is a process for all partner agencies to identify the lessons that can be learned from particularly complex or serious safeguarding adults cases, where an adult in vulnerable circumstances has died or been seriously injured and abuse or neglect has been suspected. As a result of a detailed review, the Panel recommends changes to improve practice and services in the light of these lessons.
The aim of the process is to learn lessons and make improvements, rather than blaming individual people or organisations. It relies on a spirit of openness to learning about what went well, as well as what could be improved. The process is based on national guidelines and has been agreed by all agencies who are members of the Dorset Safeguarding Adults Board. The Safeguarding Adults Review Panel is chaired and all serious case reviews are overseen by the Independent Chair of the Safeguarding Adults Board.
Deciding when to hold a Safeguarding Adults Review
The Dorset Safeguarding Adults Board has a protocol based on national guidance, which sets out the criteria for holding a Safeguarding Adults Review.
The Safeguarding Adults Review Panel considers referrals for Safeguarding Adults Reviews. The panel makes recommendations to the Independent Chair of the full Board on whether a Safeguarding Adults Review should be held or if other steps can be taken to respond to the issues that a case has raised. These decisions are based on our published policy on safeguarding adults reviews.
Anyone can make a referral to the Safeguarding Adults Review Group by contacting the Independent Chair of the Safeguarding Adults Board.
How a Safeguarding Adults Review is carried out
The Review Panel draft terms of reference for the Safeguarding Adults Review. Each agency involved in the case, including any independent providers involved, arranges for an Individual Management Review (IMR) to be carried out by a manager independent of the case. The IMR reviews the agencies involvement and actions in the case. It has to address relevant aspects of the terms of reference and be based on a set format including a chronology, a review of recorded information and interviews with the key people involved.
An IMR writer can be a suitably skilled and experienced manager from the agency or an independent person commissioned by the individual agency. The completed IMRs are given to the panel and to an independent Overview Report Writer who uses them and any further inquiries they decide to make, to produce an overview report and a draft summary report, including recommendations on actions or changes needed.
The overview report and draft summary report is presented to the Safeguarding Adults Review Panel. The panel reviews the report and recommended actions. These are then presented to the Safeguarding Adults Board for the senior representatives from each agency on the board to consider and agree the proposed actions needed. It then monitors the implementation of these actions with the help of the Safeguarding Adults Review Panel. The summary report is published and made available to the public.
Safeguarding Adults Review Reports
It was agreed that findings from the Safeguarding Adults Reviews should be shared as widely as possible in order to enhance learning and inform practice.
Simon
Access learning from the 2023 Safeguarding Adults Review 'Simon':
- Safeguarding Adults Review - Learning from the circumstances around the death of Simon
- System Learning findings from SAR Simon
Katherine
Access learning from the 2021 Safeguarding Adults Review 'Katherine':
- Safeguarding Adults Review in Rapid Time 'Katherine'
- 7 minute briefing: System learning findings from Safeguarding Adults Review 'Katherine'
- 7 Golden rules of information sharing from Safeguarding Adults Review 'Katherine'
Earlier Safeguarding Adults Reviews
Access learning from earlier Safeguarding Adults Reviews:
- Safeguarding Adults Review - HNH, 2016
- 7 minute learning - multi-agency risk management (MARM)
- 7 minute learning - learning about contractures
- 7 minute learning - learning from a SAR in a nursing home in Dorset
- Safeguarding Adults Review report - JT Executive summary 2012 and DSAB action plan - JT
- Safeguarding Adults Review report - LW 2011 and Overview report - LW, 2011
Purbeck Care Serious Case Audit
Following the events that eventually led to the closure of Purbeck Care Home, the Dorset Safeguarding Adults Board arranged for a review of the services that went into the home to see if there were any lessons to be learned for agencies about whether things could or should have been done differently. Access the findings:
- Report from the audit of what occurred
- Executive summary of the report
- Purbeck Care Serious Case Audit - easy read version
- Action plan resulting from the audit
- Press release dated 11 February 2015
- Easy read version of the press release dated 11 February 2015