What Is a Safeguarding Adults Review (SAR)? Care Act Section 44 Explained

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1. 1What is a Safeguarding Adults Review (SAR)?
2. 2What is the legal test for a SAR under section 44 of the Care Act 2014?
3. 3Who decides whether a SAR happens, and who sits on a Safeguarding Adults Board?
4. 4What happens in a SAR, step by step?
5. 5What should frontline staff and managers expect if their service is involved?
6. 6How do you refer a case for a SAR, and what makes a good referral?
7. 7What lessons do SARs keep repeating?
8. 8How is a SAR different from other reviews and investigations?
9. 9What happens after a SAR, and is anything changing in 2026?
10. 10What are the rules in Wales, Scotland and Northern Ireland?
11. 11What should a manager or safeguarding lead do to prepare for a SAR?
12. 12What training helps staff understand and contribute to safeguarding reviews?
13. 13Frequently asked questions

This guide is for managers, safeguarding leads and frontline staff whose service might be asked to contribute to a review. It describes the Care Act arrangements in England, checked on 28 October 2026. Here “SAR” means a safeguarding adults review, not a suspicious activity report. For the wider framework, see our guide to safeguarding adults. General information, not legal advice.

What is a Safeguarding Adults Review (SAR)?

A SAR is a multi-agency review of a case, held to understand what happened and why. Section 43 of the Care Act 2014 requires every local authority to establish a Safeguarding Adults Board, and section 44 requires that board to arrange a review in the circumstances the Act sets out. Section 44 came into force on 1 April 2015.

The Care and Support Statutory Guidance, chapter 14 (the guidance), is clear about the purpose. Paragraph 14.168 says a SAR should seek to determine what the agencies and individuals involved “might have done differently that could have prevented harm or death”, so that lessons can be applied to future cases. It adds that the purpose “is not to hold any individual or organisation to account”, because other processes exist for that: criminal proceedings, disciplinary procedures, employment law and regulation, such as by the Care Quality Commission (CQC).

That matters for staff. Paragraph 14.169 warns that if people and organisations fear SARs, their participation will be “guarded and partial”.

What is the legal test for a SAR under section 44 of the Care Act 2014?

The test is in section 44 of the Care Act 2014. An SAB must arrange 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 both of these apply:

1. A concern about joint working. There is reasonable cause for concern about how the SAB, its members or other persons with relevant functions worked together to safeguard the adult (section 44(1)(a)).
2. One of two conditions is met. Condition 1 (section 44(2)): the adult has died and the SAB knows or suspects that the death resulted from abuse or neglect, whether or not it knew or suspected the abuse or neglect before the death. Condition 2 (section 44(3)): the adult is alive and the SAB knows or suspects that they have experienced serious abuse or neglect.

Three points follow from the wording. The board needs to “know or suspect”, not to have proof or a conviction. The adult need not have received services, which paragraph 14.165 repeats. And both limbs are needed: as drafted, a death from abuse or neglect does not by itself trigger the duty without reasonable cause for concern about joint working.

For a living adult, “serious” is not defined in the Act. Paragraph 14.163 gives examples: the person would have been likely to have died but for an intervention, or has suffered permanent harm, or has reduced capacity or quality of life. Self-neglect is among the types of abuse and neglect listed in chapter 14, although the guidance notes it may not prompt a section 42 enquiry.

Section 44(4) adds a discretion: a board may review “any other case” involving an adult with care and support needs in its area, and paragraph 14.164 says SARs can also explore good practice. Section 44(5) requires every board member to co-operate in and contribute to a review, to identify lessons and apply them to future cases.

Who decides whether a SAR happens, and who sits on a Safeguarding Adults Board?

The SAB decides. Schedule 2 to the Act sets its members: the local authority that established it, an integrated care board whose area overlaps with the authority’s, and the chief officer of police for an overlapping police area. Others may be added by regulations or by the local authority after consulting the other core members. The authority appoints the chair, and the board regulates its own procedure. Paragraph 14.150 recommends considering an independent chair, and paragraph 14.146 lists likely extra members, including ambulance and fire services, housing providers, probation, GPs, Healthwatch, CQC and independent care providers.

One point of currency: paragraph 14.145 still refers to clinical commissioning groups, but the Act as amended names integrated care boards (since 1 July 2022), and the guidance carries a notice that it is under review.

Boards should be able to show how they decided. The West Midlands regional SAR guidance (December 2025), one example of local practice, says decisions should be lawful, reasonable and rational, with reasons recorded, and that they can be challenged by judicial review. Boards vary, so check yours.

What happens in a SAR, step by step?

Section 44 prescribes no method; paragraph 14.170 says the process “should be determined locally”. The steps below combine the guidance with local protocols such as the West Midlands guidance, and your board’s order and terms may differ.

1. Referral. Someone tells the board about a case that may meet the criteria (see below).
2. Screening. The board checks the case against section 44, often at a multi-agency rapid review meeting, and records its decision and reasons.
3. Terms of reference and reviewer. The guidance says terms of reference should be published (paragraph 14.166) and that serious cases should be reviewed by someone independent of the case and of the organisations involved (paragraph 14.167). The West Midlands guidance describes rapid reviews, traditional panel reviews with individual management reviews, and action-learning models such as SCIE’s Learning Together.
4. Information. Agencies supply records and chronologies, and the board can require information under section 45.
5. The adult and their family. Paragraph 14.165 says early discussions should agree how the adult, family and friends wish to be involved. For a living adult or a discretionary review, section 68 requires an independent advocate if the adult would otherwise have substantial difficulty being involved and no suitable unpaid person can support them.
6. Analysis and learning. Depending on the method, this may include learning events with the practitioners and managers involved.
7. Report. It should be in plain English with findings of practical value (paragraph 14.178). The board should aim to finish within six months unless there are good reasons, such as prejudice to court proceedings (paragraph 14.173).
8. Publication and action. The board should consider publishing within the legal limits on confidentiality (paragraph 14.179) and follow through the action plan (paragraph 14.170).

Real reviews do not always run smoothly. The national analysis (see below) found delays in commissioning reviews, poor-quality individual management reviews, hesitant information-sharing and unclear approaches to family involvement. Some bereaved families were not supported, and taking part can re-traumatise if it is not managed sensitively.

What should frontline staff and managers expect if their service is involved?

You may be asked to secure and provide records, supply a chronology of your contact with the person, write a short account of your involvement, be interviewed, attend a learning event, and check a draft for accuracy.

The duty to co-operate is legal. Under section 45 of the Care Act 2014, a person asked by an SAB for information must comply if the request is to help the board exercise its functions, the person is likely to hold relevant information, and (in outline) it relates to them, their functions or activities, or someone in respect of whom they exercise a function or engage in an activity. The board may use the information only for its functions. Paragraph 14.185 adds that anyone who knows abuse or neglect is happening must act, not wait to be asked.

Is a SAR a disciplinary process? No, but be precise. The guidance says professionals “should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith” (paragraph 14.167), and that a SAR is not about holding anyone to account (paragraph 14.168). Disciplinary, regulatory and criminal routes exist separately, though, and a SAR does not stop them. So tell the truth, stick to the facts and follow your employer’s policies.

Our suggestions for managers, beyond what the guidance requires:

• Tell the staff involved early, say what the review is and is not, and name one contact.
• Do not alter records. If a late entry is needed, date it as such and say why.
• Build the chronology from the records, in date order, separating fact from opinion.
• Ask what support is available. The national analysis noted that SARs pay little attention to practitioners’ lived experience of the work.

Good recording and clear referrals make this easier. Our Safeguarding Adults (Advanced) Level 2 course covers how to recognise, respond to, record and refer concerns.

How do you refer a case for a SAR, and what makes a good referral?

Neither section 44 nor chapter 14 sets out a national referral form or route, so each board sets its own. The West Midlands regional form, for example, says any individual or organisation working with adults should inform the safeguarding partners, after discussing the case with their designated safeguarding lead or manager, as soon as possible after the incident.

A SAR looks back to learn. If an adult is at risk now, raise a safeguarding concern with the local authority immediately, and call 999 if anyone is in immediate danger.

Based on that regional form, a good referral includes:

• the adult’s details, care and support needs, and the date of the death or incident
• a brief summary, including earlier safeguarding concerns, referrals and meetings
• the type of abuse or neglect, and why you think the case meets the criteria, especially any concern about joint working
• a short list of key events, not a full chronology
• other agencies, family members and advocates involved
• any police investigation or coroner’s inquiry, and what has been done to keep the adult safe if they are alive

Stick to facts and records, avoid blame, and say what learning might be gained.

What lessons do SARs keep repeating?

The best evidence is the Second national analysis of safeguarding adult reviews, a Local Government Association and ADASS (Partners in Care and Health) project led by Michael Preston-Shoot and Suzy Braye with Conn Doherty and Helen Stacey, published in 2024. It covers SARs completed in England from April 2019 to March 2023; all 136 SABs responded and 675 SARs were completed, of which 652 were analysed. The Stage 1 report found self-neglect in 60 per cent of SARs (up from 45 per cent in the first national analysis), neglect and acts of omission in 46 per cent (from 37), and domestic abuse in 16 per cent (from 10). It also found that 82 per cent of the individuals featured had died by the time of the review.

The Stage 3 report sets out repetitive findings:

• Mental capacity. The Mental Capacity Act has produced “repetitive findings about misunderstanding of its five principles and lack of confidence in undertaking mental capacity assessments”. See our Mental Capacity Act guide.
• Working together. Poor understanding of agencies’ roles, duties and powers, weak information-sharing, silo-working and no case co-ordination.
• Section 42. Repeated non-compliance with the duty to make enquiries, and uncertainty about what to do when its criteria are not met.
• Organisational pressure. Absence of management oversight, lack of supervision and specialist advice, and workload pressures.
• Care settings. No effective systems for identifying and responding to provider concerns in cases of organisational abuse.
• Access. Five per cent of SARs featured denied or difficult access and the lack of a power of entry.
• Direct practice. Continuing concerns about Making Safeguarding Personal, professional curiosity and risk management.

These show up in everyday work. Hoarding and self-neglect raise capacity and access dilemmas, while cuckooing, financial abuse and coercive control are cases where curiosity and information-sharing matter. The report also found that SARs tend to “start again” rather than build on earlier reviews, and that none of the sampled SARs was commissioned specifically to learn from good practice or a near miss.

The first national analysis, Analysis of Safeguarding Adult Reviews, April 2017 – March 2019 (Preston-Shoot, Braye, Preston, Allen and Spreadbury, December 2020), reported that reviews commissioned rose from 90 in 2015-16 to 135 in 2018-19.

How is a SAR different from other reviews and investigations?

A death or serious incident can trigger several processes at once. They have different purposes and legal bases, and a SAR replaces none of them.

Boards are expected to manage overlaps. Paragraph 14.175 says a board should consider how a SAR can dovetail with a domestic homicide review, criminal investigation or inquest running in parallel, and paragraph 14.176 says the SAR manager should contact the chair of any parallel process to reduce duplication. The Home Office guidance on domestic abuse related death reviews (September 2026) also covers running them alongside SARs. The national analysis found no national guidance on what to do when a referral meets the criteria for more than one review, so local protocols matter.

What happens after a SAR, and is anything changing in 2026?

Schedule 2 requires each SAB’s annual report to cover the findings of reviews that concluded in the year, ongoing reviews, what the board has done to implement the findings, and its reasons where it decides not to implement one. The guidance says the same (paragraph 14.177). The West Midlands guidance notes that publication may be delayed until a criminal investigation or inquest concludes, and the national analysis found that some boards publish only a summary, withhold some SARs or remove reports after about a year. A National SAR Library, hosted by the National Network for SAB Chairs, collects completed reviews, but not every board submits theirs.

National oversight is developing. The verified facts, dated:

• Baroness Casey, chair of the Independent Commission on Adult Social Care, wrote to the Health Secretary on 3 March 2026. A GOV.UK letter of 22 June 2026 says the government has established a new National Adult Safeguarding Board, chaired by the Chief Social Worker for Adults and reporting to the Minister of State for Care.
• Its terms of reference (July 2026) include an urgent review of adult safeguarding legislation, updating the safeguarding chapter of the statutory guidance, whether councils should have to escalate SARs to national level, and better data on section 42 enquiries and section 44 SARs.
• The summary of its first meeting, on 16 June 2026, says the scope includes reviewing sections 42 and 44 and assessing proposals for powers of entry and protection orders, with a guidance update due to the Board in October 2026.
• A blog of 6 August 2026 says a Challenge Group set up in March 2026 had agreed proposed actions on all escalated SARs, and urges boards to escalate reviews with national learning.

On 28 October 2026 the wording of section 44 was unchanged on legislation.gov.uk and we found no new SAR guidance published, so check GOV.UK before relying on a paragraph number.

What are the rules in Wales, Scotland and Northern Ireland?

The Care Act arrangements above are those in England. Each nation has its own system.

Northern Ireland has separate arrangements, which we could not verify against an official source, so we do not describe them. Check with your Health and Social Care Trust or the Department of Health.

What should a manager or safeguarding lead do to prepare for a SAR?

A practical checklist, based on the guidance and regional protocols (the steps are our suggestions):

1. Know your SAB’s SAR referral route and policy.
2. Agree who will co-ordinate your response and who will speak to staff.
3. Secure all records about the person at once, including notes, emails, rotas, care plans, incident reports and supervision records, and pause routine deletion.
4. Build an accurate chronology from the records, with sources.
5. Tell the staff involved early and explain what support is on offer.
6. Gather what you already know: earlier concerns, complaints, audits, referrals and any internal investigation.
7. Take legal advice on disclosure if there is a police investigation or inquest.
8. Be ready to share what worked as well as what did not.
9. After the report, assign owners to the actions and test whether the changes are really happening; the national analysis found little evidence of the impact of completed reviews.

What training helps staff understand and contribute to safeguarding reviews?

The national evidence points to repeated gaps in understanding of mental capacity and multi-agency working, and says domestic abuse was not consistently recognised as an adult safeguarding issue. Three Nexis CPD courses fit this topic:

Together they cost £18 rather than £27 under the pay-for-2-get-3 offer, and employers training 5 or more staff pay £6 a course place on our team plan. These are awareness-level CPD courses, not regulated qualifications, and they do not replace your organisation’s safeguarding procedures, specialist training or your SAB’s policies. If you take one, start with Safeguarding Adults (Advanced) Level 2: 15 questions, 80% to pass, and an instant certificate.

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Frequently asked questions

What is a safeguarding adults review in simple terms?

It is a legal review, arranged by the local Safeguarding Adults Board under section 44 of the Care Act 2014, of a case where an adult with care and support needs has died or been seriously harmed through abuse or neglect and agencies may not have worked together well enough. It aims to find lessons, not to blame individuals.

Who can ask for a safeguarding adults review?

The Act sets no national referral route, so each board decides. The West Midlands regional form, for example, says any individual or organisation working with adults should inform the safeguarding partners after discussing the case with their safeguarding lead. Check your board’s website for its form.

Will staff be disciplined because of a SAR?

A SAR is not a disciplinary process. The statutory guidance says it is not to hold any individual or organisation to account, and that professionals should contribute without fear of being blamed for actions taken in good faith. Separate employer, regulatory or criminal processes may still exist.

Are safeguarding adults review reports published?

The guidance says boards should consider publishing reports within the legal limits on confidentiality, and records should be anonymised through redaction or consent sought. Regional guidance notes that publication may be delayed, for example until a criminal investigation or inquest concludes.

What is the difference between a SAR and a section 42 safeguarding enquiry?

A section 42 enquiry decides what action should be taken to protect an adult at risk now. A SAR is a retrospective learning review of how agencies worked together, arranged by the SAB, usually after a death or serious harm.

Does the SAR system apply in Wales, Scotland and Northern Ireland?

This article describes England. Wales uses the Single Unified Safeguarding Review from 1 October 2024, and Scotland uses initial and significant case reviews under a Scottish Government framework. Northern Ireland has separate arrangements.

General information, not legal advice. If someone is in immediate danger, call 999. This guide reflects the Care Act 2014, the Care and Support Statutory Guidance and the sources named above as checked on 28 October 2026; the statutory guidance is under review, so check GOV.UK for the current position. Arrangements differ in Wales, Scotland and Northern Ireland, and each Safeguarding Adults Board sets its own local procedures. Nexis CPD courses are CPD-accredited awareness training, not regulated qualifications, and they do not replace your organisation’s safeguarding procedures or local multi-agency policy.