Safeguarding adults review (SAR): what a care provider is asked for

What triggers a safeguarding adults review: section 44 of the Care Act 2014

A Safeguarding Adults Board must arrange a multi-agency safeguarding adults review when two things are true at once: there is reasonable cause for concern about how the agencies worked together to safeguard an adult with care and support needs, and the adult has died from known or suspected abuse or neglect, or is alive and is known or suspected to have experienced serious abuse or neglect. Every local authority in England must set up a Board for its area under section 43 of the Care Act 2014, and the duty to review is in section 44, in force since 1 April 2015 and unamended. Its words:

• 44(1): “An SAB 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.”
• 44(2), condition 1: “(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).”
• 44(3), condition 2: “(a) the adult is still alive, and (b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.”
• 44(4): “An SAB 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).”
• 44(5): “Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to– (a) identifying the lessons to be learnt from the adult's case, and (b) applying those lessons to future cases.”

Three points in that text are easy to get wrong. First, a death from abuse or neglect does not on its own make a review mandatory: the concern about how the agencies worked together is the other half of the test. Second, the adult need not have been receiving care the council arranged or paid for; the section applies “whether or not the local authority has been meeting any of those needs”, and the statutory guidance adds that the adult “need not have been in receipt of care and support services” at all. A self-funding resident of a care home is covered. Third, section 44(4) lets a Board review any other case it chooses, so a SAR can also look at a case that falls outside the mandatory test, or at good practice worth spreading; the guidance says SARs “may also be used to explore examples of good practice”.

“Serious” in condition 2 is explained in paragraph 14.163 of the Department of Health and Social Care's Care and Support Statutory Guidance: “something can be considered serious abuse or neglect where, for example the individual would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect.” So a near miss, where the adult survived only because someone intervened, can meet condition 2 and make a review mandatory.

The section 44(5) duty to co-operate binds the Board's members. Under Schedule 2 of the Act those are the local authority, the integrated care board and the chief officer of police, plus anyone else the local authority, after consulting those members, considers appropriate. A private or voluntary care provider is usually not a member, so its legal duty to take part comes through a request under section 45, covered below. Anyone can bring a case to the Board's attention: the model SAR procedure that tri.x publishes for Boards to adapt says “Any agency or professional may refer a case that they consider meets the criteria”, and that the Board reviews each referral against the criteria, with its chair making the final decision. A SAR is a different process from the local authority's section 42 enquiry: the enquiry is the council's and asks what happened to one person and what should be done; the review is the Board's and asks how the agencies worked together. What a provider records during an enquiry is covered in the section 42 enquiry guide.

Outside England. Section 44 is the English regime. In Wales, adult practice reviews initiated after 1 October 2024 are carried out under the Welsh Government's Single Unified Safeguarding Review statutory guidance, which brings adult and child practice reviews and homicide reviews into one process. Scotland and Northern Ireland have their own arrangements.

What a SAR is for: learning, not blame

Paragraph 14.168 of the statutory guidance is the one to show anxious staff: “SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again. Its purpose is not to hold any individual or organisation to account.” It names the processes that do hold people to account – “criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation, such as CQC and the Nursing and Midwifery Council, the Health and Care Professions Council, and the General Medical Council” – and they are separate from the review.

The guidance explains why: “If individuals and their organisations are fearful of SARs their response will be defensive and their participation guarded and partial” (14.169). Paragraph 14.167 sets the principles every Board and its partners should apply to all reviews:

• a culture of continuous learning and improvement across the organisations that work together to safeguard adults;
• an approach “proportionate according to the scale and level of complexity of the issues being examined”;
• reviews of serious cases “led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed”;
• professionals “involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”;
• families invited to contribute, understanding how they will be involved.

The Board also chooses the kind of review. Paragraph 14.164 says it “should be primarily concerned with weighing up what type of ‘review’ process will promote effective learning and improvement action to prevent future deaths or serious harm occurring again”, which is why one SAR is a full independent review with an overview report and another is a shorter, focused exercise.

Paragraph 14.166 adds that “SARs should reflect the 6 safeguarding principles”, that the Board should agree terms of reference for each review which “should be published and openly available”, and that the records used should “either be anonymised through redaction or consent should be sought”. Read the terms of reference when they arrive: they tell you the period under review, the questions the reviewer is asking and which agencies are in scope. The six principles themselves, from empowerment to accountability, are set out in the safeguarding in care homes guide.

Learning, not blame, does not mean consequence-free. A review that finds a provider's practice fell short will say so in its report, and evidence a provider sends can reach the regulator (section 04). The honest position for a manager is that the review is the place to explain what happened and why, fully and early, while any disciplinary or regulatory question runs on its own track. Older reports, including the case study in the statutory guidance itself, use the earlier name for an adult review, a “Serious Case Review (SCR)”; that case study quotes the local policy of the time, that “the purpose of an SCR is not to reinvestigate or to apportion blame”. Since April 2015 the Care Act term is safeguarding adults review.

When the Board asks your service for information: section 45

Section 45 of the Care Act 2014 is the provision that reaches a care provider. Its text, from section 45 on legislation.gov.uk, says: “If an SAB requests a person to supply information to it, or to some other person specified in the request, the person to whom the request is made must comply with the request if– (a) conditions 1 and 2 are met, and (b) condition 3 or 4 is met.” The four conditions are:

1. Condition 1: “the request is made for the purpose of enabling or assisting the SAB to exercise its functions.” A SAB's functions include its reviews.
2. Condition 2: “the request is made to a person whose functions or activities the SAB considers to be such that the person is likely to have information relevant to the exercise of a function by the SAB.” A provider that supported the adult will usually meet it.
3. Condition 3: the information “relates to– (a) the person to whom the request is made, (b) a function or activity of that person, or (c) a person in respect of whom that person exercises a function or engages in an activity.” Limb (c) is the usual case for a provider: information about the adult it cared for.
4. Condition 4: the information “(a) is information requested by the SAB from a person to whom information was supplied in compliance with another request under this section, and (b) is the same as, or is derived from, information so supplied.” This lets the Board ask someone to pass on what they were given under an earlier request.

Where conditions 1 and 2 and either 3 or 4 are met, the provider “must comply”. Section 45 contains no exception for confidential information; the place for a concern about what is being asked is a conversation with the Board's business manager or the SAR's lead reviewer about scope. Section 45(6) limits what happens next: “Information may be used by the SAB, or other person to whom it is supplied under subsection (1), only for the purpose of enabling or assisting the SAB to exercise its functions.” Paragraph 14.184 of the guidance names the providers it has in mind as those who are not Board members, “such as private health and care providers or housing providers/housing support providers or education providers”.

The guidance also warns against waiting: “If someone knows that abuse or neglect is happening they must act upon that knowledge, not wait to be asked for information” (14.185). A provider that learns something new during a review – a staff member remembers a disclosure, a missing record turns up – should raise it then, through its ordinary safeguarding route, rather than holding it for the review.

What you will be asked for. Chapter 14 leaves the method to the Board – “No one model will be applicable for all cases” (14.170) – so the request follows the Board's own SAR procedure, and the names differ from Board to Board. Expect some combination of:

• a chronology of your service's involvement with the adult over the period in the terms of reference, built from your records (the safeguarding chronology guide covers the format);
• a written account of that involvement and what your service has learned from it, which a Board may call an individual management review, an agency report or a single agency report;
• copies of specific records: care plans and reviews, daily notes, incident and safeguarding logs, medicines records, correspondence with the council, GP and family;
• staff, and sometimes the manager, taking part in a practitioner meeting or learning event with the reviewer and the other agencies.

Give the request one named owner, usually the registered manager or the nominated individual, agree the deadline, check that what you send is within the terms of reference, and keep a dated copy of everything you send and of the request itself. Paragraph 14.171 says the Board “should ensure that there is appropriate involvement in the review process of professionals and organisations who were involved with the adult”; if your service supported the adult and has heard nothing, it is reasonable to ask the Board whether it wants to hear from you.

How long a SAR takes, the report, and what happens afterwards

The Board should aim to complete a safeguarding adults review within six months of starting it. The words are paragraph 14.173 of the statutory guidance: “The SAB should aim for completion of a SAR within a reasonable period of time and in any event within 6 months of initiating it, unless there are good reasons for a longer period being required; for example, because of potential prejudice to related court proceedings.” That is an expectation in guidance, not a deadline in the Act: neither section 44, section 45 nor Schedule 2 sets a time limit, and the paragraph's own example, related court proceedings, is one recognised reason for a longer review. The Social Care Institute for Excellence (SCIE) notes on its safeguarding adults reviews page that many reviews “can take several months to complete” and offers a SARs in Rapid Time model that “speeds up the process”.

The same paragraph says “Every effort should be made while the SAR is in progress to capture points from the case about improvements needed; and to take corrective action.” A provider does not need to wait for the final report to fix something it has already found.

Parallel processes. Paragraph 14.175 asks the Board to consider “how the process can dovetail with any other relevant investigations that are running parallel, such as a child SCR or DHR, a criminal investigation or an inquest”, and 14.176 says “Any SAR will need to take account of a coroner's inquiry, and, or, any criminal investigation related to the case, including disclosure issues”. A provider in that position may be asked for the same records by the police, the coroner and the Board; keep a single log of what went to whom and when.

The report. Paragraph 14.178 says SAR reports should “provide a sound analysis of what happened, why and what action needs to be taken to prevent a reoccurrence, if possible; be written in plain English; contain findings of practical value to organisations and professionals”. Under 14.179 the Board “should consider publishing the reports within the legal parameters about confidentiality”; published reports usually appear on the Board's own website. The National Network for Chairs of Adult Safeguarding Boards keeps a national SAR library of published reports by year, which is the quickest way to see what reviews of services like yours have found.

The annual report and the action plan. Schedule 2, paragraph 4 requires each Board to publish an annual report covering “the findings of the reviews arranged by it under section 44 … which have concluded in that year”, the reviews still ongoing, “what it has done during that year to implement the findings”, and, where it decides not to implement a finding, “the reasons for its decision”. Paragraph 14.170 adds that “The recommendations and action plans from a SAR need to be followed through by the SAB”, so a provider named in an action plan can expect to be asked to show what it has done.

CQC. Paragraph 14.177 is explicit: “All documentation the SAB receives from registered providers which is relevant to CQC's regulatory functions will be given to the CQC.” Write everything you send on the footing that the regulator may read it. The review does not replace the provider's own duties to CQC, which the CQC notifications guide sets out.

Records that stand up to a review

A SAR reads a provider's records months or years after they were written, alongside the records of every other agency. The statutory guidance's standard is in paragraph 14.180: “Good record keeping is a vital component of professional practice. Whenever a complaint or allegation of abuse is made, all agencies should keep clear and accurate records and each agency should identify procedures for incorporating, on receipt of a complaint or allegation, all relevant records into a file to record all action taken.” It continues: “When abuse or neglect is raised managers need to look for past incidents, concerns, risks and patterns,” and “In the case of providers registered with CQC, records of these should be available to service commissioners and the CQC”.

For a registered provider, Regulation 17(2)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 already requires its systems and processes to enable it to “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”. The Regulation 17 guide covers the rest of the regulation. In a review, the contemporaneous part matters most: the question is usually what the service knew on a given date and what it did next.

Paragraph 14.181 gives staff four questions about what to record: what staff need to know to give a high-quality response to the adult; what they need to know to keep adults safe; “What information is not necessary?”; and “What is the basis for any decision to share (or not) information with a third party?” Records that answer those four questions as they go are the ones that make a SAR request quick to answer.

In practice, that means:

• a safeguarding log that shows each concern, who raised it, when, what was done and who was told, cross-referenced to the person's care record;
• decisions recorded with their reasons, including decisions not to refer or not to share;
• the date and content of every contact with the council, the GP, the district nurses and the family about the concern, not only the formal referrals;
• staff told before a review starts what a SAR is, that it is about learning, what they may be asked to do, and that support is available; and
• a retention rule that keeps safeguarding records long enough to answer a review that may begin a year or more after the events (the care records retention guide covers the periods).

The care home safeguarding policy guide covers how the policy and the log fit together under Regulation 13.

What the service knew, and when: the messages around a case

A SAR asks what each agency knew and when. A provider's chronology is assembled from its care records, but in some cases the earliest signs passed between people as messages, not as entries. A night carer texts the manager that a resident seemed frightened when a visitor left. A daughter sends the key worker a WhatsApp message about bruising she noticed on Sunday. A senior tells the deputy, in the staff group, that a client's money keeps going missing. Some of that reaches the care record. Some of it may not, and the reviewer's question – when did the service first know? – is answered by the message, not the note written later.

When those messages sit in a consumer app on staff's personal phones, the provider may be unable to produce them for the Board or show who saw them and when, and can lose them when the phone or the member of staff goes. Paragraph 14.180's “all relevant records into a file” is hard to meet when the first record is on someone else's handset.

ComplyChat provides channels for those work conversations: staff, managers and, where the provider chooses, family members, with everyone added told that the channel is on the record, and a mobile number verified by SMS as each person's identity, so bank staff, night staff and relatives with no work account can take part. Messages are recorded on the server as they are sent, and on paid plans, once the provider's Microsoft 365 tenant is connected, the conversations are kept there under the provider's own retention schedules. ComplyChat is not a care records system, does not build chronologies or write management reviews, and does not replace the safeguarding log; it keeps the conversations around them.

A question for the next management meeting: if a Board asked tomorrow for everything your service knew about one person in the last twelve months, could you produce the messages as well as the notes?

Questions people ask

When should a safeguarding adults review (SAR) be held?

A Safeguarding Adults Board must arrange a SAR under section 44 of the Care Act 2014 when there is reasonable cause for concern about how agencies worked together to safeguard an adult with care and support needs, and the adult has died and abuse or neglect is known or suspected to have caused the death, or is alive and is known or suspected to have experienced serious abuse or neglect. The Board may also review any other case involving an adult with care and support needs (section 44(4)).

What triggers a safeguarding adult review?

A SAR is triggered by the two-part test in section 44(1): concern about how the agencies worked together, plus either a death resulting from known or suspected abuse or neglect, or known or suspected serious abuse or neglect of a living adult. The statutory guidance (para 14.163) says abuse or neglect can be serious where the person would probably have died but for an intervention, or has suffered permanent harm or reduced capacity or quality of life.

What are the criteria for a SAR?

The criteria are in section 44 of the Care Act 2014: an adult in the Board's area with needs for care and support, whether or not the council was meeting them; reasonable cause for concern about how the agencies worked together; and either condition 1 (death from known or suspected abuse or neglect) or condition 2 (known or suspected serious abuse or neglect of a living adult). Where they are not met, the Board can still choose to hold a discretionary review.

How long does a safeguarding review take?

The Care and Support Statutory Guidance says the Board “should aim for completion of a SAR within a reasonable period of time and in any event within 6 months of initiating it, unless there are good reasons for a longer period being required”, such as related court proceedings (para 14.173). Six months is an expectation in guidance, not a statutory deadline, and a review can run longer where there are good reasons, such as an inquest or a criminal case.

Does a care provider have to give information to a SAR?

Yes, where section 45 of the Care Act 2014 applies: a person the Board asks for information must comply when the request is to enable or assist the Board's functions, the Board considers the person likely to hold relevant information, and the information relates to that person, their functions or activities, or someone they provide a service to, such as the adult they cared for (or, under condition 4, is information passed to them under an earlier section 45 request). The Board may use the information only for its functions (section 45(6)).

How do the six principles of safeguarding adults apply to a SAR?

The statutory guidance says “SARs should reflect the 6 safeguarding principles” (para 14.166): empowerment, prevention, proportionality, protection, partnership and accountability, set out at paragraph 14.13. In a review that means, for example, involving the adult or their family, keeping the review proportionate to the issues, and being open about what is learned. The safeguarding in care homes guide explains each principle.

Official guidance and your next step

The law is in section 44, section 45 and Schedule 2 of the Care Act 2014. The guidance is chapter 14 of the Care and Support Statutory Guidance, paragraphs 14.162 to 14.186; the Department of Health and Social Care updated the guidance on 30 October 2026 to reflect system changes such as integrated care boards and to correct links. Your own Safeguarding Adults Board usually publishes its SAR procedure, referral form and any published reviews on its website, and the national SAR library collects reports from across England. Quotations are from those pages as published on 30 October 2026.

This guide is a summary for care providers in England, not legal advice about a particular review, inquest or investigation.

Then do one thing: pick one person your service supported who was the subject of a safeguarding concern in the last year, and try to build their chronology from your records alone in an hour. Where you have to ask a member of staff what happened, or look at someone's phone, that is the gap a Board's request will find.