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Safeguarding Adult Reviews (SAR's)

Purpose of a SAR

With the implementation of the Care Act 2014 there is a statutory requirement to undertake SARs when certain criteria are met. In this instance, it was commissioned because:
•there was reasonable cause for concern about how SSAB members or other agencies providing services, worked together to safeguard an adult and
•an adult died, and SSAB knew or suspected that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died)

A SAR is a multi-agency review process that seeks to determine what relevant agencies and individuals involved could have done differently that could have prevented harm or a death from taking place. The purpose of a SAR is not to apportion blame. It is to promote effective learning and improvement to prevent future deaths or serious harm occurring again.

Safeguarding Adult Review - Honor

A review commissioned by the Swindon Safeguarding Adult Board following Honor's death in January 2017, is available to view below:

Social Care Institute for Excellence Review - Honor (PDF)
SAR Statement (PDF)

Safeguarding Adult Review - Terry 

Terry died in hospital in June 2019 aged 71 from liver cirrhosis accompanied by Hepatitis C. Terry experienced self-neglect, financial abuse, neglect by informal carers and alcohol misuse in the years leading up to his death. Avaliable below is the review conducted by Michael Preston-Shoot on behalf of the Swindon Safeguarding Partneship.

Safeguarding Adult Review - Kieran

Kieran died at his home in January 2019 following a period of illness. Kieran was diagnosed with mild learning disabilities around the age of 18 and first had contact with mental health services following his father’s death 3 years later. He experienced self – neglect, hoarding, mental illness and exploitation in the years leading up to his death. Avaliable below is the review conducted by Michael Preston-Shoot on behalf of the Swindon Safeguarding Partneship.

SAR Kieran Executive Summary

SAR Kieran Full Report

SAR Kieran Learning Brief

SSP Action Plan proforma (to be completed alongside the Learning Brief)

Safeguarding Adult Review - Alison

Alison was a 49-year-old woman who was found collapsed in a stream in woodland near her home in July 2020.   It was determined that she had taken her own life. Alison reported a history of trauma as well as chronic mental health problems and a pattern of alcohol misuse. She had been engaged with the local Mental Health Services for at least 25 years. She also had poor physical health with chronic liver disease and asthma. She lived alone and although she had family, contact was limited. Avaliable below is the review conducted by Mike Ward on behalf of the Swindon Safeguarding Partneship.

Safeguarding Adult Review - Andrew

Andrew was a 77 year old male who on the Sept 20 was found unresponsive inside a property besides his adult son who was found deceased at the scene. Andrew subsequently passed away in hospital. Since that time both deaths have been ruled as suicide by the coroner. Andrew was open to Safeguarding Adults team within Swindon Borough Council with a Section 42 enquiry on-going at the time of his death. Andrew lived alone and had a number of health conditions. There is evidence from practitioners’ reports that Andrew began to show signs of self- neglecting behaviours including a deterioration in his living environment, the cancellation of a care package from domiciliary care agency and poor self-care.  Themes identified in the report include;  Lack of recognition of complexities of and plan to safeguarding against Intergenerational Domestic Abuse. Focus on social care needs as outcome for Safeguarding activity at the expense of investigating abuse. Professional curiosity and working with unwise decision making. Co-ordinated and effective multi-agency working. Effective QA in Safeguarding across agencies. Avaliable below is the rreport written by Helen Rankin on behalf of the Swindon Safeguarding Partneship.