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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.