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TDSAP Safeguarding Adults Reviews Panel Member and Practitioner Responsibilities

What is a Safeguarding Adults Review (SAR)?

Under Section 43 of the Care Act (2014) each Local Authority must establish a Safeguarding Adults Board (SAB).  The SAB has a statutory duty under Section 44 of the Care Act (2014) to commission Safeguarding Adults Reviews (SARs).

Here within Torbay and Devon, our SAB is known as the Torbay and Devon Safeguarding Adults Partnership (TDSAP).  The TDSAP is responsible for commissioning SARs under the following circumstances:

Where an adult with needs for care and support (whether or not the local authority has been meeting them) has either

died and the death is thought to be a result of abuse or neglect

remains alive and is thought to have experienced serious abuse or neglect
and (in either case)

There is reasonable cause for concern about how the TDSAP, its members or other persons with relevant functions worked together to safeguard them.

The TDSAP can also decide to undertake a SAR in any other situations involving an adult with care and support needs.

The objective of all SARs is to determine what relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death.    The purpose of the review is not to apportion blame but to arrive at recommendations that inform achievable smart actions that can be taken forward by partners to improve future responses for adults with care and support needs and keep them safe from abuse and neglect.

When a SAR referral is received by the TDSAP, it will be considered by the SAR Core Group to determine whether the SAR criteria has been met.

Where it is agreed that the SAR criteria has been met, a SAR Panel will be established with suitable senior representation from the partner organisations involved in the case.

The role of the SAR Panel is to:

  •  Agree the terms of reference with the Lead Reviewer,
  •  Scrutinise and critically analyse all information being submitted,
  •  Consider the findings and conclusions,
  •  Make recommendations in relation to what action is required to address the learning identified.

The SAR Panel will consider, amend as necessary and finalise the SAR Report prior to its submission to the TDSAP for ratification and sign off.

Once recommendations and action plan(s) are agreed it will be the responsibility of the TDSAP Learning and Improvement Subgroup to monitor the implementation of action plan(s) across partner agencies.

What happens to the information that is shared?

The information that organisations share within the SAR process helps to build a comprehensive picture of what happened and in turn will support identification of suitable recommendations for change.  These recommendations will then be converted into smart actions to facilitate the changes needed in practice and procedures.

How long will the SAR process take?

The time taken to complete a SAR is dependent on several factors including how much information needs to be gathered and the number of partner agencies involved. The TDSAP expect SAR panel members to be responsible for providing appropriate updates to their organisation and any practitioners involved in the case as to how the review is progressing.

What does the SAR produce?

A SAR report identifying the findings and recommendations is produced and will normally be published on the TDSAP website. The report will be anonymised unless it has been agreed with the person and/or their family/ representatives to publish identifying information. Practitioners involved with the case will not be named in the final SAR report.

Any learning that is identified within the report will be implemented across the relevant agencies and best practice that has been highlighted will also be shared to ensure that safeguarding practice continues to improve across the Torbay and Devon Safeguarding Adults Partnership footprint.

SAR Panel Member responsibilites

SAR panel members have a key role and professional responsibility within the SAR process.  Organisations must be robust in selecting their nominated panel member ensuring they are of requisite seniority to be able to fully secure their organisation’s full participation in the SAR. The panel member must not have been directly involved in the first line management or frontline care of the Adult(s) concerned.

Panel members must be aware of the time commitment required to participate within this process.  As a panel member, attendance at and preparation for each meeting is expected. The nomination of any deputy is only permitted under exceptional circumstances and in agreement with the Lead Reviewer as continuity is crucial to the process.

Panel members are expected to undertake an assessment of good practice, what might have been done differently or better and recommend how to embed this learning into practice and/or procedures. This will also include supporting the Lead Reviewer to convey and address any urgent learning points that may emerge back into their organisation while the SAR is in progress.

The SAR Panel will support the Lead Reviewer to formulate and finalise recommendations as part of the SAR report which will:

  •  Clearly demonstrate what smart actions are required to address each recommendation
  •  Clearly demonstrate who will be responsible for each action
  •  The intended outcome of each action
  •  The means for monitoring and reviewing intended improvements in practice and/or systems

How do practitioners involved with the adults(s) participate in SARs?

The TDSAP expects that your organisations’ SAR panel member would have had a discussion to inform you, the practitioner, of the reasons for the SAR and the process that will be undertaken.

It is important to remember that the purpose of the SAR is not to apportion blame but to seek essential learning and arrive at recommendations that inform achievable smart actions that can be taken forward by partners to improve future responses for adults with care and support needs and keep them safe from abuse and neglect.

The TDSAP recognise that practitioner experiences are central to the SAR process to enable appropriate learning to be identified.  It is likely that as your organisation prepares its’ information to share with the SAR panel, that you will be engaged in conversations to understand what happened and explore, what if anything, might have been done differently.

It may also be decided by the SAR panel that a Learning Event facilitated by the Lead Reviewer may be helpful to highlight where practice worked well and aid the learning and improvement process to inform a first draft of the SAR report.   Practitioners nominated to attend such an event are ideally expected to have had direct involvement with the Adult(s), however this is not essential.

If asked by your organisation to attend a SAR learning event, it is expected that you would have familiarised yourself with the case.  It is also expected that you attend (exceptional circumstances must be discussed with your line manager or relevant panel member if you cannot attend) and fully engage in a first-hand collaborative process to gain maximum learning from the review.

Any practitioner that is worried about a SAR and what this might mean for them is encouraged to speak with their line manager and/or their organisations’ SAR panel member.


More information regarding Safeguarding Adults Reviews can be viewed here

For more information on the Torbay and Devon Safeguarding Adults Partnership, its Partners and its work click here

June 2023



Last Updated