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 Networks 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.

Section 44 SARs are different and separate from the Local Authority-led Section 42 Safeguarding Enquiries.

Read this 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

The SAR Sub-group usually reviews SAR referrals in four to six weeks of receipt. Referrers would usually be invited to present their referral at the SAR Sub-group meeting. Recommendation on whether the case meets the criteria for a SAR is made to the RWSAB Executive, who make the final decision. The referrer is then informed of the decision.

Systems learning approach

The videos below give a brief overview of the importance and reasons for using and participating in a systems approach to learning from Safeguarding Adults Reviews (SARs).