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Safeguarding Adult Review Reports


Click below for a brief summary of each Safeguarding Adult Review (SAR) and links to overview reports and practice briefings.


Sam was a white British man who died by suicide at the age of 47 years old. He had a diagnosis of Persistent Delusional Disorder, which is characterised by irrational or intense beliefs or suspicions that the person believes to be true.

A safeguarding adult review referral was received by SSAB, and although Sam’s case did not meet the criteria for a review, learning was identified from both the good practice and areas where practice could be improved.



Stephen was a 59-year-old man with mental and physical health difficulties who died by choking in 2018.

Learning themes are risk assessment, carers assessment, mental capacity and DoLS, professional curiosity, dispute resolution, and accountability in safeguarding practice.




Paul was a 44-year-old man who slept on the streets and experienced drug and alcohol addiction. He experienced abuse and exploitation both when accommodated and when sleeping rough. His death in 2019 was concluded to be alcohol and drug related.

Learning themes are transitions, taking a holistic approach to assessment, legal literacy, and the impact of conditional support.





Rachel was a 20-year-old woman who had been a victim of sexual abuse as a child, had a history of poor mental health and was also a victim of sexual exploitation and trafficking from the age of 17 until her death, which was concluded to be drug related, in 2016.

Learning themes are social model of consent, National Referral Mechanism awareness, information sharing without consent, risk assessment, and transitions child to adult.




Graham was a 50-year-old man with physical disabilities, who died in 2018 of respiratory infection.

Learning themes were support for carers, whole family approach, hospital discharge, domestic abuse, and mental capacity.



John is a 37-year-old man with a learning disability and autism who experienced significant abuse from family members until he was supported to move to residential home in 2016.

Learning themes are holistic assessment with due consideration of wellbeing principle, importance of advocacy, information sharing, monitoring of direct payments, whole family approach, working with evasive people, and accurate record keeping.



Mr S experienced poor mental health and used drugs and alcohol routinely. He died by suicide in 2015, having left hospital where he was being treated for a drug overdose.

Learning themes are hospital handovers, effective escalation of staff shortages, clarification of roles and responsibilities, missing persons procedures, and information sharing.