Adult Safeguarding Reviews

Safeguarding Adults Reviews (SARs) aim to determine what the relevant agencies and individuals involved in a 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.

More information can be found in the serious adult review policy (PDF 255Kb), and Single Agency Health Review (PDF 612Kb)  the Joint SCR SAR Protocol (PDF 1.4Mb).


Please email your completed referral form to Stockport’s Safeguarding Adults Board Business Manager at

The Statutory guidance for the Care Act outlines for following criteria for a Safeguarding adults review:

  • If an adult dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult
  • If an adult in its area has not died, but the Safeguarding Adults Board knows or suspects that the adult has experienced serious abuse or neglect and the individual would have been likely to have died but for an intervention
  • If an individual 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

January 2019

Stockport Safeguarding Adults Board commissioned a safeguarding adults review regarding an adult, known as Elizabeth, who sustained fractures and bruising whilst living at home. Elizabeth was 87 years old. She lived in a one-bedroomed first floor flat and she had two sons who both spent extended periods of time living with her.

It was reported that from the injuries Elizabeth sustained, there was no medical treatment sought for 4-7 days, and since then, she had been in bed immobilised.

There was previous concerns relating to financial exploitation, and the buzzer to Elizabeth’s flat had also been disconnected along with concerns of compliance with her medication.


November 2018

SAR was completed in November 2018. Female aged 93 years old who was a resident in a Nursing home. She was diagnosed with dementia and was very frail. Mrs Grant had a do not attempt cardio pulmonary resuscitation (DNACPR) in place. Her health had deteriorated in the weeks before her death and in this time she required assistance to eat whilst at the home.

 The following report explains the outcomes of the SAR that has been anonymised. Any names and initials included in these document are fictitious. Condolences are given to family and friends for the loss of their loved one.


September 2018

A SAR was undertaken and the final report was endorsed by Stockport Safeguarding Adults Board in September 2018.

Ann was a 77 year old woman with a diagnosis of Chronic Schizophrenia who suffered from several issues, including self-neglect, which was linked to her mental ill health. The learning from the review can be found in the final overview report.


August 2018

Stockport’s Safeguarding Children Board and Stockport Safeguarding Adults Board commissioned an independent joint Safeguarding Adult Review and Serious Case Review to identify learning and improvement in relation to the circumstances of Annie’s death and the impact of the events leading up to this on her teenage children.

The Board commissioned Independent Reviewers, Paul Kingston and Emma Mortimer to complete the review. All agencies involved, and Annie’s family and friends contributed to the Review.

The Board partners have been working hard to address the issues identified in the report, in order to improve the way agencies work together.

Our heartfelt sympathies are extended to Annie’s family and friends for their tragic loss.


Helen – July 2017

This report is about Helen who lived in supported accommodation from where she was admitted to hospital in September 2014 suffering from nausea and persistent vomiting.

Helen stayed in the same hospital until her discharge on 12 January 2015 to a care home for rehabilitation. On 27 January 2015 Helen was readmitted to the hospital because of her deteriorating health. Helen sadly died in hospital on 17 February 2015 aged sixty-one years.