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Safeguarding Adult Reviews (SARs)

The purpose of a SAR

With the implementation of the Care Act 2014, there is a statutory requirement to undertake safeguarding adult reviews (SARs) when certain criteria are met. In this instance, a SAR was commissioned because:

  • there was reasonable cause for concern about how Swindon Safeguarding Adults Board (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 this was known or suspected 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 to prevent harm or death from taking place.

The purpose of a SAR is not to apportion blame. Its aim is to promote effective learning and improvement to prevent future deaths or serious harm occurring again.


Safeguarding Adult Review - Ferdynand (August 2025)


Safeguarding Adults Review - Sally (September 2024)


Safeguarding Adults Review - Ethan (July 2024)


Safeguarding Adults Review - Richard (July 2024)


Safeguarding Adults Review - Wendy (May 2024)


Safeguarding Adults Review - Robert (March 2024)


Accessing older reports

Reports that are more than 18 months old are removed from the website. However, you can request copies from the SSP Business Unit by emailing safeguardingpartnership@swindon.gov.uk.

Older SAR reports

Safeguarding Adults Review - Summer (November 2023)


Safeguarding Adult Review - Frankie (October 2023)


Safeguarding Adult Review - Brian (February 2022)

Themes include; mental health, physical health, self-neglect and drug use


Safeguarding Adult Review - Brenda (June 2021)

Themes identified include self-neglect and physical health needs.


Safeguarding Adult Review - Andrew (September 2020)

Themes include; safeguarding against Intergenerational Domestic Abuse, professional curiosity and working with unwise decision making.


Safeguarding Adult Review - Alison (July 2020)

Themes include; history of trauma, chronic mental health problems, physical health with chronic liver disease and asthma and alcohol misuse.


Safeguarding Adult Review - Kieran (January 2019)

Kieran experienced self–neglect, hoarding, mental illness and exploitation in the years leading up to his death.


Safeguarding Adult Review - Terry (June 2019)

Terry experienced self-neglect, financial abuse, neglect by informal carers and alcohol misuse in the years leading up to his death


Safeguarding Adult Review - Honor (January 2017)

Themes include domestic abuse (financial abuse, neglect and psychological abuse)