Safeguarding Adults Board

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.

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.  The SAR Panel Process and Notification Report Template can be found here.

Please contact the Boards Business Manager if you have any queries in regards to published SARs or the SAR process on

Safeguarding Adults Reviews

Practice note on the Case of Louise and a Podcast detailing the learning from the SAR author new published June and July 2022

Full report on the Case of Adam and Practice Note -new published May 2022

Practice note on Case of Steven

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 Ken,  Practice 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 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

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. The full report and action plan can be found on West Berkshire Council's website.

Wokingham Domestic Homicide Review 2015 executive summary.  The full report and action plan can be found on Wokingham Council's website.

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.