Safeguarding Adult Reviews

Safeguarding Adult Reviews (SARs) were previously known as Serious Case Reviews. They are held when an adult with care and support needs dies or suffers significant harm as a result of abuse or neglect.


Safeguarding Adult Reviews are not inquiries into how someone died or suffered injury, or to find out who is responsible.


  • Look at any lessons we can learn from the case about the way professionals and agencies worked together
  • Review the effectiveness of our safeguarding adults procedures
  • Inform and improve practice
  • Identify what can be done better to avoid a similar circumstance from reoccurring

The SAB aims to share learning from Safeguarding Adult Reviews widely with local organisations and through the London and National Safeguarding Network across London and nationally.

When are they held?

Section 44 of The Care Act 2014 requires Safeguarding Adults Boards to undertake a Safeguarding Adult Review when specific criteria are met. This is when abuse results in the death or significant and possibly life-changing harm of an adult with care and support needs.

Read Government information about the Care Act 2014 and SARs.

What is a Safeguarding Adults Review? - Information for families and carers in Richmond and Wandsworth

Make a referral

Anyone may make a SAR referral, by completing the SAR referral form. It is recommended that you refer to the SAR criteria contained in the SAR Protocol.

Send your completed form by email to, or by post to:

Head of Safeguarding and Professional Services
Adult Social Care
The Town Hall Extension
6th Floor
Wandsworth High Street
SW18 2PU

The SAR Subgroup usually makes a decision relating to any SAR referral within four weeks of receipt, and will inform the referrer of the decision made.

SAR reports and documents

The following reports explaining the outcomes of recent SARs have been anonymised. Any names and initials included in these documents are fictitious.



Seven-minute briefings

Seven-minute briefings are based on a technique borrowed from the FBI. Learning for seven minutes is manageable in most services. Learning is more memorable as it is simple and not clouded by other issues and pressures. Their brief duration should also mean that they hold people’s attention, as well as giving managers something to share with their staff. The briefings will not have all the answers, but it is hoped that they will act as a catalyst to help teams and their managers to reflect on their practice and systems. The expectation is that team leaders will present briefings to their staff, on a regular basis.