There was a 14.6% increase in abuse concerns of abuse being raised in 2019/20[1], this increased by 5% the following year[2]. Combined with the disruption of the pandemic, this highlights the need for strong and consistent safeguarding policies across the board.

Learning lessons from Safeguarding Adult Reviews is vital when improving service delivery, as they help evaluate practice and identify how services can improve.

What are Safeguarding Adult Reviews?

Safeguarding Adult Reviews were made mandatory for all local authorities by the Care Act (2014). By examining safeguarding failures, they improve service provision and work to prevent similar harms from happening again. Reviews aren’t there to hold people to account as there are processes in place that already exist for that, they are simply there to help organisations learn from past safeguarding actions [3].

By looking at how Safeguarding Adult Boards carry out reviews trends can be identified that aid the improvement of safeguarding interventions. A national review of SARs created a national picture, highlighting trends and ways to improve the delivery of safeguarding adults nationwide.

National Analysis of Adult Safeguarding Reviews


Data collected from 231 cases looked at the 5 domains involved in SARs to ensure a full picture was created in the analysis and to highlight specific improvements needed at each level. The 5 domains are:

  • Direct Work with the Adult
  • Interagency Team around the individual
  • Organisational support around the team
  • Safeguarding Adult Board Governance
  • Legal policy and financial context of adult safeguarding

It was important to engage with all of the domains to understand how the complete SARs came together and what information may have been disregarded. It also highlighted the similarities and differences in cases nationwide. Highlighting these differences brought to light national shared issues in safeguarding and potential areas SABs need greater support from government as part of the 2019-25 Safeguarding strategy.[4]

Key Findings

The key findings are split into the governance of SABs and what can be learnt from the 231 cases analysed. Findings on the governance of SABs can be immediately implemented, helping authorities be more compliant with the guidelines as set out by the 2014 Care Act.

Analysis of SAB governance highlighted a common misunderstanding in local authorities of the mandates in the Care Act (2014). There was often reference to statutory and non-statutory guidance in the reviews when all SARs are mandated by the care act. All SABs have statutory requirements to publish annual reports outlining the work of the board over the previous 12 months and how partner agencies have worked together to improve the safety of adults at risk of abuse.

Protected Characteristics

Acoss the 231 cases reviewed, protected characteristics were often omitted. The omission of protected characteristics does comply with the Equality Act (2010) to protect individuals from any discrimination[5]. However, these omissions raise concerns on the amount of attention SARs pay to discrimination that may have influenced the support provided to the adult.

Failing to identify protected characteristics in a review neglects to address any role discrimination may have played in the overall safeguarding failure.

Recommendations for Best Practice

Improvements should be made across the domains in the safeguarding framework to better service provision. Changes in policy should align SABs with national policy, working in line with the Safeguarding Strategy 2020 to improve safeguarding practices.

Direct Work with the Adult

  • Safeguarding practices need to be person-centred so a strong relationship can be formed with the adult in question.
  • Any transitions in care need to be presented as opportunities for the adult to maintain their autonomy.
  • A range of specialist advice needs to be available to the adult so they can understand what is best for their care.
  • Thorough histories need to be taken to understand the adult’s past and the role this may have in the safeguarding concern.
  • Assessment of care and mental health needs should take place.
  • The involvement of the family needs to be considered in the treatment plan.
  • Those working with the adult need to understand the legal terms relevant to the safeguarding concern.
  • The person’s autonomy needs to be balanced with the duty of care those working them have.

Most importantly, there must be an assessment and review of the risk the individual is at from the safeguarding concern raised.

Inter-organisational environment

The inter-organisational environment bridges external organisations with those who are working directly with the individual. Bridging the gap means that the inter-organisational environment is responsible for communicating any information that is important to the safeguarding case.

  • Inter-organisational environments need to guide those working directly with the individual on how to balance their autonomy with the duty of care.
  • They have to define clear roles and responsibilities for the agencies and key workers who work directly with the individual.
  • Work together as a unit to provide support on complex safeguarding cases  that may have stalled.
  • Share and communicate any useful information with the relevant agencies to ensure continual multi-agency improvement.

Organisational Environment

The organisational environment is the individual service responsible for the safeguarding of a person, such as a hospital or a care home.

  • The organisation needs to support staff and provide access training to improve the care staff provide.
  • They are required to develop and share guidance reviews so staff can improve the care they provide.
  • They should clarify management responsibilities and oversee the care provided in safeguarding cases.

SAB Governance

  • SABs are responsible for reviewing management in SARs and need to highlight where safeguarding failures occurred to identify where systems need to improve.
  • SABs should use SARs to improve services by using them to inform policy development and practice.
  • SABs need to constantly review case outcomes to allow for continual improvement.


These changes are only the starting point for improving safeguarding practices. Safeguarding Adult Boards must seek continual reassurance that recommendations are embedded throughout the safeguarding framework. They need to then monitor these changes to develop an understanding of how safeguarding services can improve in the long term.

[1]NHS Digital, Safeguarding Adults England 2019/20, (2020)
[2] NHS Digital, Safeguarding Adults England 2020/21, (2021)
[3] Department of Health and Social Care, Care Act 2014, (2014)
[4] Professor Michael Preston-Shoot, University of Bedfordshire, (2021)
[5] Department for Health, Safeguarding Adults and the Role of Health Services Analysis on the impact on Equality, (2011)

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With a 14.6% increase in abuse concerns in 2019/20, the need for strong and consistent adult safeguarding policies has become increasingly essential. Using Safeguarding Adult Reviews, service providers can help identify areas for improvement to prevent abuse, and concerns surrounding abuse, from occurring.

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