Safeguarding Adults Boards have a duty be assured that local safeguarding arrangements are in place as defined by the Care Act 2014 and statutory guidance. Part of this duty is to carry out a Safeguarding Adult Review (SAR) when an adult at risk dies as a result of abuse or neglect, whether known or suspected, or is still alive but has experienced serious abuse or neglect and; there are concerns that partner agencies could have worked more effectively to protect the adult.
Non-statutory Learning Reviews
Sometimes the criteria for a Safeguarding Adult Review are not fully met, but it is still considered that lessons could be learned to improve the ways that organisations and their staff work together to safeguard adults with care and support needs. In such situations a non-statutory Learning Review (Discretionary SAR) will be carried out and a report will be published.
Domestic Homicide Reviews
A domestic homicide review (DHR) is a multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship, or a member of the same household as themselves.
Responsibility for the commissioning of Wolverhampton’s Domestic Homicide Reviews sits with the Safer Wolverhampton Partnership.
s44 of the Care Act 2014 states that:
A Safeguarding Adults Board must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—
(a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and
(b) condition 1 or 2 is met.
Condition 1 is met if—
(a) the adult has died, and
(b) the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).
Condition 2 is met if—
(a) the adult is still alive, and
(b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.
A Safeguarding Adults Board may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).
The purpose of a SAR is to promote effective learning and improvement action to prevent future deaths or serious harm occurring again. The aim is that lessons can be learned from a case and those lessons applied to future cases to prevent similar harm happening again.
A SAR is not an enquiry into the cause of an individual death or injury. It does not look for someone to blame and it is completely separate from any investigation being undertaken by the police or a coroner.
Wolverhampton Safeguarding Together has adopted the Rapid Review process introduced within Working Together to Safeguard Children (2018) for all new SAR Referrals which are to be progressed for further scoping and information gathering from partner agencies.
The purpose of a rapid review is to:
• gather the facts about the case, as far as they can be readily established at the time
• discuss whether there is any immediate action needed to ensure the adults safety and share any learning appropriately
• consider the potential for identifying improvements to safeguard and promote the welfare of adults with care and support needs
• decide what steps they should take next.
All agencies who have been involved with the subject adult or will be required to contribute to the rapid review. An initial scoping of agencies’ intervention will be completed, and other relevant information will need to be rapidly gathered.
The purpose of the initial scoping and information sharing is to gather the basic facts about the case, including determining the extent of agency involvement with the adult.
More detailed information will be sought if the rapid review concludes the case has the potential to identify national or local learning and a decision is made to recommend a Safeguarding Adult Review.
Published in 2026:
Helen
Published in 2025:
Thomas
Patrick
Published in 2024:
Beth
Published in 2026:
Published in 2025:
Published in 2024:
