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Safeguarding Adults Reviews

Safeguarding Adult Reviews (SARs) are about learning lessons for the future. They will make sure that Safeguarding Adults Boards get the full picture of what went wrong, so that all organisations involved can improve their practice. Under the Care Act each member of the SAB must co-operate in and contribute to the carrying out of a review.

West of Berkshire Safeguarding Adults Board SAR Process

The SAR Panel has developed a process for SARs in order to ensure that:

  • We have processes for learning and reviewing that are flexible and proportionate and open to professional and public challenge.
  • We can determine locally what type of review is appropriate dependent on the nature of the case and the agencies involved.
  • A culture of transparency is created that provides for a positive shared learning culture.

This document sets out the Boards’ expectations for a Safeguarding Adult Review of a serious case, within which there is room for professional judgement and flexibility.

Under the Care Act each member of the SAB must co-operate in and contribute to the carrying out of a review. The Board has set out a process for Board members, managers and practitioners, in order to clarify the different roles and responsibilities of individual agencies, the Safeguarding Adults Board and its Subgroups. This includes a notification report template to be completed by anyone wishing to present a case for consideration by the SAR Panel. This is the SAR Panel Process and Notification Report Template.This is the SAR Panel Process and Notification Report Template.

Please contact the Boards Business Manager if you have any queries in regards to published SARs or the SAR process on lynne.mason@reading.gov.uk

Safeguarding Adults Reviews

Safeguarding Adults Reviews commissioned by this Board  are published below, either as an executive summary or a full report. This section will be added to as more documents become available. 

Full report on the Case of Bree and Practice NoteNew published March 2024

Full report on the Fire Safety SAR and Practice Note those that support vulnerable adults are strongly encouraged to attend the Royal Berkshire Fire and Rescue Services Adult at Risk Programme Training, as well as seeking out training opportunities around fire risk within their organisations.

Full report on the Case of Tina and Practice Note

Full report on the Case of Sandra and Practice Note

Full report on the Case of Pauline, Practice Note, Webinar detailing the learning from Pauline, Presentation from webinar New published July 2023

Practice note on the Case of Louise and a Podcast detailing the learning from the SAR author 

Full report on the Case of Adam and Practice Note 

Practice note on Case of Steven in June 2022 the SAB held a bitesize learning session in regards to learning from this case, the recording can be found here.

Practice note on Case of John

Full report on the Case of P 2020 (published December 2020) and Practice Note

Full report on the Case of KenPractice Note and Statement from the Board

Practice note on Case of Margaret

Full report on the Case of Graham 2020 and Practice Note  

Practice note on Case of Henry 2020

Full report on the Case of Carol 2020,Practice Note

Full report on the Case of Ben 2020, Practice Note

Full report on the Case of Michelle 2020, Learning Brief

Full report on the Case of Paul 2019,Practice Note

Full report on the Case of Daniel 2019, Summary Presentation, Practice Note and Statement from the Board

Practice Note on the Case of Gemma 2019

Full report on the Case of Aubrey 2018 and Practice Note Aubrey

Full report on the Case of Mrs H 2016 and Briefing Note Mrs H

Full report on the Case of Mr I 2016 and Briefing Note Mr I

Findings from the Case of Ms F 2014

Slough Safeguarding Adults Board – Mrs EE

A SAR was not undertaken for the Case of X (2017) but the Board considered learning that was already available from local and national cases so as not to duplicate efforts. In particular, the case of Mr I completed in 2016 was noted as containing similar themes.

West Berkshire Council Domestic Homicide Review 2016 executive summary. This is the full report and action plan.

Wokingham Domestic Homicide Review 2015 executive summary.  This is the full report and action plan.

Safeguarding Adults Reviews library

The Safeguarding Adults Reviews library commissioned by the Department of Health is being developed jointly by Research in Practice for Adults (RiPfA) and Social Care Institute for Excellence (SCIE), working closely with colleagues from the sector.

The Safeguarding Adults Review (SAR) library will contain reports and associated resources to support those involved in commissioning, conducting and quality assuring SARs.