Safeguarding Adults Reviews

Safeguarding Adult Reviews (SARs) are about learning lessons for the future. They will make sure that Safeguarding Adults Boards get the full picture of what went wrong, so that all organisations involved can improve their practice. Under the Care Act each member of the SAB must co-operate in and contribute to the carrying out of a review.
 

West of Berkshire Safeguarding Adults Board SAR Process

The SAR process below is currently under review following the change from the West of Berkshire Safeguarding Adults Board to West Berkshire Safeguarding Adults Board. We will update this document once the new version has been produced.

The West of Berkshire Safeguarding Adults Board SAR panel have an agreed  process for its SARs [323KB] :

• we have processes for learning and reviewing that are flexible and proportionate and open to professional and public challenge
• we can determine locally what type of review is appropriate dependent on the nature of the case and the agencies involved
• a culture of transparency is created that provides for a positive shared learning culture

This document sets out the Boards' expectations for a Safeguarding Adult Review of a serious case, within which there is room for professional judgement and flexibility.

Under the Care Act each member of the SAB must co-operate in and contribute to the carrying out of a review. The Board has set out a process for Board members, managers and practitioners, in order to clarify the different roles and responsibilities of individual agencies, the Safeguarding Adults Board and its Subgroups. This includes a  notification of case for consideration template [54KB]  to be completed by anyone wishing to present a case for consideration by the SAR Panel.
 

Published Safeguarding Adults Reviews

Safeguarding Adults Reviews commissioned by this Board are published below, either as an executive summary or a full report. This section will be added to as more documents become available.
 

These SARs were all produced under the previous tri-borough West of Berkshire Safeguarding Adults Board.

Ursula SAR - published April 2025

• Full report on the case of Ursula [1MB]
• Ursula SAR: executive summary [180KB]
• Ursula SAR: video - Rebecca Berry, SAR Author and Lynne Mason SAB Business Manager, who have recorded their reflections on the learning from the Ursula SAR and how this can be used in ongoing practice
   

Louis SAR - published March 2025

• Full report on the case of Louis [2MB]
• Louis SAR: video
   

Vihad SAR - published March 2025

• Full report on the case of Vihad [686KB]
• Vihad SAR: podcast
   

Case of Bree - published March 2024

• Full report on the Case of Bree [399KB]
• Case of Bree: Practice Note [372KB]
   

Fire Safety SAR - published December 2023

• Full report on the Fire Safety SAR [426KB]
• Fire Safety SAR: Practice Note [205KB]

Those that support vulnerable adults are strongly encouraged to attend the Royal Berkshire Fire and Rescue Services Adult at Risk Programme Training, as well as seeking out training opportunities around fire risk within their organisations.
 

Case of Tina - published 2023

• Full report on the Case of Tina [254KB]
• Case of Tina: Practice Note [287KB]
   

Case of Sandra - published 2023

• Full report on the Case of Sandra [308KB]
• Case of Sandra: Practice Note [350KB]
• Case of Sandra: Podcast - Rebecca Berry, Head of Adult Safeguarding and Quality Assurance, Wokingham Borough Council and Sue Brain, Service Manager Safeguarding Adults, West Berkshire Council have recorded their reflections on the learning from the Sandra SAR and how this can be used in ongoing practice
   

Case of Pauline - published 2023

• Full report on the Case of Pauline [478KB]
• Case of Pauline: Practice Note [1MB]
• Case of Pauline: webinar detailing the learning
• Case of Pauline: presentation from webinar [703KB]
   

Case of Louise - published 2023

• Practice note on the Case of Louise [712KB]
• Case of Louise: Podcast detailing the learning from the SAR author
   

Case of Adam - published 2022

• Full report on the Case of Adam [280KB]
• Case of Adam: Practice Note [651KB]
   

Case of Steven - published 2022

• Practice note on Case of Steven [222KB]
• Steven bitesize learning session - in June 2022 the SAB held a bitesize learning session in regards to learning from this case
   

Case of Ken - published 2021

• Full report on the Case of Ken [423KB]
• Case of Ken: Practice Note [180KB]
• Case of Ken: Statement from the Board [171KB]
   

Case of John - published 2020

• Practice note on Case of John [792KB]
   

Case of P - published 2020

• Full report on the Case of P 2020 [1MB]
• Case of P: Practice Note [223KB]
   

Case of Margaret - published 2020

• Practice note on Case of Margaret [589KB]
   

Case of Graham - published 2020

• Full report on the Case of Graham 2020 [370KB]
• Case of Graham: Practice Note [280KB]
   

Case of Henry - published 2020

• Practice note on Case of Henry 2020 [388KB]
   

Case of Carol - published 2020

• Full report on the Case of Carol 2020 [295KB]
• Case of Carol: Practice Note [647KB]
   

Case of Ben - published 2020

• Full report on the Case of Ben 2020 [213KB]
• Case of Ben: Practice Note [290KB]
   

Case of Michelle - published 2020

• Full report on the Case of Michelle 2020 [595KB]
• Case of Michelle: Learning Brief [336KB]
   

Case of Paul - published 2019

• Case of Paul: Practice Note [468KB]
   

Case of Daniel - published 2019

• Full report on the Case of Daniel 2019 [379KB]
• Case of Daniel: Summary Presentation
• Case of Daniel: Practice Note [497KB]
• Case of Daniel: Statement from the Board [289KB]
   

Case of Gemma - published 2019

• Practice Note on the Case of Gemma 2019 [291KB]
   

Case of Aubrey - published 2018

• Full report on the Case of Aubrey 2018 [249KB]
• Case of Aubrey: Practice Note [526KB]
   

Case of Mrs H - published 2016

• Full report on the Case of Mrs H 2016 [802KB]
• Case of Mrs H: Briefing Note [359KB]
   

Case of Mr I - published 2016

• Full report on the Case of Mr I 2016 [728KB]
• Case of Mr I: Briefing Note [563KB]
   

Case of Mrs EE - published 2015

• Slough Safeguarding Adults Board: Mrs EE [63KB]
   

Case of Ms F - published 2014

• Findings from the Case of Ms F 2014 [30KB]
   

Other reviews

• Case X (2017): a SAR was not undertaken for the  Case of X (2017) [609KB]  but the Board considered learning that was already available from local and national cases so as not to duplicate efforts - in particular, the case of Mr I completed in 2016 was noted as containing similar themes
• Domestic Homicide Reviews (DHR): find West Berkshire Council's published Domestic Homicide Reviews here

Safeguarding Adults Reviews library

The Safeguarding Adults Reviews library commissioned by the Department of Health is being developed jointly by Research in Practice for Adults (RiPfA) and Social Care Institute for Excellence (SCIE), working closely with colleagues from the sector.

The Safeguarding Adults Review (SAR) library will contain reports and associated resources to support those involved in commissioning, conducting and quality assuring SARs.