Safeguarding Adult Reviews (SARs) - The SAR process
The information in the tabs below explains the process of completing a safeguarding adult review (SAR) from submitting a referral through to the methods which might be used to complete the review.
Any agency can make a referral for a SAR if they identify a case where they believe that the criteria for a SAR are met. Examples of how a case might be identified are:
During a Safeguarding investigation an Inquiry officer or chair identifies a case an agency may identify a case that hasn't had a safeguarding investigation e.g. police may identify that a case they have been investigating meets the criteria for a SAR.
The coroner, MPs and Elected Members of Salford City Council may have a case brought to their attention where they feel a SAR referral is appropriate referrals can be made by family members, carers and members of the public
Requests for a SAR must be made in writing using the referral form, which should be completed as fully as possible and returned to Salford Safeguarding Adults Board on the SAR email address - SAR.firstname.lastname@example.org
Escalation through internal management structure
Where a professional or volunteer working for an agency has identified a possible SAR referral, the case should first be considered internally within the organisation at the appropriate level. Each agency/organisation needs to decide how any SAR referral will be verified internally before the referral is made to the Safeguarding Adults Board. This process should be clearly communicated to staff and noted in any single agency safeguarding adults policy.
If the incident triggers a mandatory investigation or review within the organisation concerned (e.g. NHS serious incident investigation or coroner's Reg 28 notice) this should take place as a matter of priority, but a referral for a SAR (if appropriate) should not be delayed and should be made at the same time. Internal governance processes and multi-agency reviews are not mutually exclusive.
How a SAR referral is processed:
- SAR referral is emailed to SSAB using the SAR email address
- SAR referral is assessed and details checked as required
- SSAB manager makes an assessment of the additional information required for the referral to go the panel (in consultation with the SAR panel if required)
- A case summary proforma is sent out to agencies for them to complete outlining their involvement with the individual please note in some cases this may not be deemed necessary for the SAR panel to make a decision
- Agency proformas must be returned within 10 days
- Returned case summaries will be collated and SAR referral will be scheduled for consideration by the next scheduled SAR panel.
- The SAR panel, acting on behalf of the SSAB, will make a recommendation to the independent chair for any review they feel should be conducted (statutory or non statutory)
- The independent chair will make the final decision
- All SSAB members will be given the opportunity to comment on the appropriate methodology for any SAR agreed.
How is the decision communicated?
The referrer and relevant statutory directors will be informed of the outcomes of the SAR request and the reasons for the decision.
If a SAR has been agreed a letter will be sent to the chief executives of all relevant agencies (and copied to their respective SSAB member) to notify them of the decision to commission a SAR and the methodology to be used. The lead member of the council will also be notified.
The designated safeguarding lead in the CCG will provide single point of contact for informing/notifying other health providers
A log of SAR referrals and agreed outcomes is held by Salford Safeguarding Adults Board.
Further options if a request for a SAR is turned down
If a request for a SAR is turned down, and where the requester is dissatisfied with this outcome, they should notify the Chair of Salford SAB in writing (via the SSAB Business Manager), who will discuss and review (if necessary) the decision with the requester and the sub group of Board members who decided on the initial request If a decision not to hold a SAR is upheld, the requesting agency can choose to take no further action or to undertake an internal review using an appropriate methodology.
Any actions from a Section 42 Safeguarding enquiry must continue to be implemented along with any actions in the protection plan.
Cross boundary issues in relation to responsibility for a SAR
There will be cases where adults have moved from their 'home' area and may be placed and funded by an organisation that is outside the provider's area. If that is the case, a SAR should be carried out by the SAB that is responsible for the location where the serious incident took place. SABs and organisations should cooperate across borders, and requests for the provision of information should be responded to as a priority.
If agreement cannot be reached on the requirement for a SAR to be undertaken then this will be resolved in the first instance by the relevant Board Managers, with ultimate decision making and discussion being resolved by the Independent Chair of the SAB. Independent Chairs will agree on the mechanisms for presenting SARs that have cross border learning.
The CCG have agreed a protocol and form for requesting information in out of area SAR referrals.
The SAR panel is a sub group of the SSAB and holds monthylmeetings a to review SAR referrals and make a decision on behalf of the SSAB. Additional meetings can be convened if necessary to ensure that referrals are considered by the panel within the time frames outlined in this policy.
This sub group is made up of SSAB members or agency representatives at an appropriately senior level. Core membership is made up of members from the CCG, GMP, ASC & Local Authority, and there must be core membership for the panel to be quorate.
The SAR panel is chaired by an SSAB member from one of the core partner agencies. Other panel members can deputise in the chairs absence.
Additional agency representatives attend as appropriate for the cases being considered (e.g. Salford Royal Hospital & GMMH).
The role of the SAR panel
The primary role of the SAR Panel is to consider all SAR referrals to determine if there is a statutory obligation to conduct a SAR (i.e. whether the referral meets the criteria outlined in 2.1.1 or 2.1.2).
A SAR must be commissioned if there is a statutory requirement to do so.
Non Statutory SARs
In cases other than those involving a statutory obligation, the SAR panel will carefully consider whether commissioning a non-statutory SAR would be a worthwhile exercise: i.e. if a multi-agency review process has the potential to identify sufficient lessons to enhance partnership working, improve outcomes for adults and families and prevent similar abuse and neglect in the future.
Considering the following questions may help to establish whether there are sufficient lessons to be learned and value in commissioning a non-statutory SAR.
- Was there a "near miss"?
- Does the case indicate that there may be failings in how adult safeguarding multi-agency policies and procedures function, leading to serious concerns about how professionals/services work together?
- Did the system not recognise/share evidence of risk of significant harm to an adult (or recognise/share it late)?
- Is there evidence that system conditions lead to poor multi-agency working or communication?
- Does that case involve serious or systemic organisational abuse and multiple alleged perpetrators, from which learning could be transferred to other organisations to prevent such abuse or neglect in the future?
- Could the case potentially yield systems learning around how agencies work together to prevent and reduce abuse and neglect that would help us do things different in the future?
- Would a SAR on the case enable the SAB to be proactive and pre-emptively tackle practice areas or issues before harm arises?
- Does intelligence from other quality assurance and feedback sources (e.g. audits/ complaints) suggest that the kind of issue in this case is new/ complex/repetitive and conducting a SAR would therefore be beneficial?
- Has this happened before (in Salford or elsewhere) and was a SAR commissioned then? Has the learning from any previous SARs been implemented or is there new learning to be identified?
- Is there adverse media interest or serious public concern?
- Is there evidence of sufficient good practice that could be mainstreamed across the partnership to the benefit of adults and their families?
The Chair of the SAR panel should also consider whether another review or learning process has already been commenced that will identify and share lessons to be learned, or which the SSAB could potentially feed into to avoid duplication (e.g. Domestic Homicide Review or Serious Incident process).
The role of the SAR panel
The SAR panel will also maintain oversight of any on-going reviews (statutory or non statutory) that the panel has recommended to ensure that actions are identified and learning appropriately disseminated.
The Decision to conduct a SAR
The final decision to conduct a SAR is made by the SSAB chair considering the rational and recommendations of the SAR panel.
SAR panel decision - reaching a consensus
In deciding on a recommendation to the independent chair in relation to a SAR, the SAR panel should aim for consensus, not a majority view. If the sub group cannot come to a consensus, then the SSAB Independent chair must be made aware of this and the differing views so that they can be fully aware of all perspectives in making the decision.
Making Decisions on SAR methodology
The SAR panel should consider and recommend an appropriate methodology for the SAR with their recommendation to the independent chair. There should be a brief rationale for this outlining why their choice is appropriate and the most proportionate to the case under review. If the decision of the independent chair is that a SAR will be commissioned then SSAB members should be consulted regarding the methodology and commissioning options available.
Conducting the SAR Review
Once the SSAB chair has decided to conduct a SAR into a particular case and determined the preferred methodology to be used, the following need to be put in place:
- A SAR Review group
- A lead reviewer (either commissioned or appointed from within the Salford Partnership if appropriate)
- A Review Group chair (this could be the lead reviewer)
The Review Group
If a SAR request is agreed, then a Review Group will need to be established with a chair. The Review group chair needs to have sufficient independence from the case and the core agencies involved.
The SSAB chair will invite the preferred candidate to chair the panel and brief them on the agreed methodology, TOR and required timescales.
The Review Group will oversee the governance of this particular review - the group should have a senior representative from each of the provider services involved but this representative must not have actually been involved in the case. Membership should also include a representative from each of the core partnership agencies with appropriate seniority and experience with regard to the case under review. Other review team members could include partner agencies not involved in the case who will bring a different perspective to the group e.g. commissioners or a voluntary sector partner.
Responsibilities of the Review Group
The Review Group will:
- Determine the TOR for the SAR which will include timescales for completion of the SAR and how learning from the SAR will be disseminated and embedded
- Determine how the adult at risk and/or their family and/or appropriate representative, can be involved in the process and kept informed on its progress. The views of the adult at risk and/or their representative must be sought and reflected in discussions, in the final reports and its recommendations.
- Establish what evidence is required from each agency or person, and whether this will be collected by investigation or individual management reviews or any other way.
- Request further information from agencies as required.
- Identify relevant policy, practice or procedures, nationally and locally, that may be relevant to the conduct of the review.
- Consider the facts and circumstances of the case and the evidence received.
- Consider how the SAR will co-operate with any related SCR or DHR.
- Consider relevant professional and practice standards and guidance.
- Take into account the nature and extent of legal advice required, in particular - Data Protection, Freedom of Information, and the Human Rights Act.
- Analyse the evidence to understand why the incident took place. In particular, the Panel will look for any wider systemic issues as well as individual practice issues.
- Identify any areas of effective practice and areas for improvement; Examine and identify relevant action points.
- Agree the key points to be included in reports and action plans and agree the final version of the Review Report and Public Summary Report.
If, during the review, further information or issues emerge that require notification to a statutory body, such as CQC, Department of Education, Health and Care Professional Council, the Nursing and Midwifery Council, Home Office, General Medical Council, Health and Safety Executive regarding significant omissions by individuals or organisations, this should be reported to the Chair of the Adult Safeguarding Board straight away and they will agree how to proceed and who will make the notification.
They will also make the decision about whether the SAR needs to be suspended during such a notification.
The Review Group: Responsibilities of the Chair
The Chair of the Review Group is responsible for:
- Setting Review Group meeting dates and agendas as required.
- Inviting all nominated representatives from relevant agencies to Review Group meetings.
- Ensuring the review is conducted according to the terms of reference and methodology.
- On-going liaison with the police and/or coroner's office as required.
- Arranging early discussions with the adult(s) and their family/ representatives, and requesting the arrangement of any support they require to participate.
- Initiating the preparation and implementation of media and communication strategies as necessary, or the obtaining of legal advice.
- Requesting any data/evidence/reports from partner agencies as required.
Role of the SSAB Business Manager & Senior Administrator
The SSAB Business Manager will work closely with the Senior Administrator to co-ordinate the SAR process outlined in this policy and ensure that identified time frames are adhered to.
This will include setting dates for SAR panel meetings, receiving referrals, verifying information, requesting proformas of agency involvement, collating info on a referral to go to the SAR Panel, setting the SAR panel agenda, sending out correspondence to referrers and others as outlined in the policy following a SAR panel.
If a SAR or other review is agreed by the SSAB Independent chair then additionally the Business manager will support with the commissioning of the Independent Reviewer if necessary and co-ordinating the ongoing work of the Review Team.
Adult and/or family involvement and independent advocacy
Adults and/or families should be invited and supported to contribute to SARs if they wish to do so, in order that an inclusive approach is taken and that their wishes, feelings and needs are placed at the heart of the review.
The SAR Review Group Chair must attempt to make contact with the adult(s), their family and/or representatives early on (ideally before the first SAR Review Group meeting) to establish:
- Why and how a SAR will be undertaken into their (family member's) case.
- How they would like to be involved - e.g. views contributed via telephone conversation, or interview, or attendance at SAR meetings.
- Any support or adjustments they would need to facilitate their involvement.
- Their initial views, wishes, concerns, and any answers/outcomes they would like to achieve from the SAR.
Reasonable and appropriate support and adjustments should be made as required to enable the adult(s), their family and/or representatives to participate in the SAR.
This may include, but is not limited to:
- Easy read large print and/or translated materials.
- Access to an interpreter.
- Support from a chosen chaperone or representative.
- Longer meeting times.
- Pre-meeting briefings and post-meeting de-briefs.
- Access to a statutory independent advocate.
If there is no appropriate person to support and represent the adult(s), then Salford SSAB must arrange for an independent advocate (under Section 68 of the Care Act).
Arrangements should be made in line with Salford's standard policy and procedures for arranging advocacy.
Alternatively, if the relevant criteria are met, appropriate partners can arrange for an independent mental capacity advocate (IMCA) or an independent mental health advocate (IMHA) to support and represent the adult(s). If an independent advocate, IMCA or IMHA has already been arranged for the adult(s), e.g. during assessment and care support planning or for a safeguarding enquiry, then the same advocate should continue to be used.
As soon as a SAR has been agreed, staff and volunteers that have had involvement in the case should be notified of this decision by their agency. The nature, scope and timescale of the review should be made clear at the earliest possible stage to staff, volunteers and their line managers. It should be made clear that the review process can be lengthy.
It is important that all relevant staff and volunteers of agencies are given an opportunity to share their views on the case as appropriate to the review methodology selected. The methods used to do this will be determined on a case by case basis by the review team. This should include their views about what, in their opinion, could have made a difference for the adult(s) and/or family. All agencies must support staff and practitioners involved in a SAR to "tell it like it is", without fear of retribution, so that real learning and improvement can happen.
Agencies are responsible for ensuring their own staff and volunteers are provided with a safe environment to discuss their feelings and offered support where needed. The death or serious injury of an adult at risk will have an impact on staff and volunteers, and needs to be acknowledged by the agency. The impact may be felt beyond the individual staff and volunteers involved, to the team, organisation or workplace.
Professional conduct issues arising
The purpose of a SAR is not to apportion blame to an individual or an agency but to learn lessons for future practice. It is important that this message is conveyed to staff and volunteers.
Issues of professional conduct may become apparent during a SAR, but it is not within the remit of the SAR panel to deal with these. Where concerns about an individual's practice or professional conduct are raised through the SAR process, they must be fed back to the relevant agency through the SAR Review Group Chair.
It then remains the responsibility of the individual agency to trigger any action in proportion with the concerns passed on by the SAR Review group.
The Lead Reviewer
The lead reviewer leads the review and writes the final report with recommendations that go to the SSAB. The lead reviewer is either commissioned or appointed by the SSAB Business Manager in consultation with the SAR Panel.
A SAR referral will be verified, and proformas sent out to agencies to request additional information within 10 working days of receiving the referral (this could include consultation with the SAR panel if it is not clear whether the criteria are met).
Agencies will be asked to complete their proforma outlining their agency involvement (during a given time frame) in chronological order within 10 working days The information will be collated and considered by the SAR panel at the next scheduled bi-monthly meeting - this will usually enable a referral to be considered by the panel within within 2 months of the SSAB having received the referral.
If a SAR is conducted the Review Team will work to a time frame of completing the review within 6 months of it being commissioned. All agencies will be given 10 days to comment on the draft review report.
The SAR panel will draw up an action plan from any review report within 2 months. The SAR Panel will decide on appropriate time frames for each review action plan, this should not exceed 12 months for completion.
The Chair and SAR Panel members are responsible for ensuring the Review Report and Public Summary are drafted and delivered within timescales, and are consistent with the terms of reference.
The Report should bring together all the relevant information with an analysis of events, and should include recommendations, where appropriate.
The report should cover:
- An account of events and factual findings with a chronology developed from individual management reviews already submitted.
- Any matters of concern affecting the safety and well being of adults at risk.
- Any general public health, safety or wellbeing issues arising from the death of an adult at risk.
- Any need to review policy, practice or procedures.
- Dissemination to other local authorities.
- Identification and integration of learning points from published Safeguarding Adults Reviews, from other areas of research and best practice guidance.
- Information on references and sources used to prepare the report.
When the report is considered to meet the requirements, the SAR Panel will:
- Send a draft of the report to contributing agencies, inviting comments on factual accuracy.
- Invite contributing agencies to confirm they are satisfied that their information is fully and fairly represented in both report.
- Invite agencies to confirm that the draft recommendations, as they apply to their agency or more generally, are clear.
It is important to note that agencies are not being asked whether they agree with the report or its findings. The focus is on ensuring the report is factually accurate, understood and recommendations are clear. Agencies have 10 working days to respond.
The Panel will consider all comments and agree the final version of both the Review report and public summary to be submitted to the SSAB for sign off.
Review Report and Public Summary will be submitted to the Adults Safeguarding Board for sign off.
Acting on the recommendations of the SAR
The SAR Panel will translate learning from the SAR report into recommendations and a proposed multi-agency action plan if required within 2 months of the report being agreed by the SSAB. The action plan should be endorsed at senior level by each organisation to whom it relates.
- The multi-agency action plan will indicate:
- The actions that are needed.
- Responsibilities for specific actions.
- Timescales for completion of actions.
- The intended outcomes: what will change as a result?
- Mechanisms for monitoring and reviewing intended improvements.
- The processes for dissemination of the SAR report or its key findings.
Individual agencies may also be asked by the SSAB to produce their own internal action plans if required.
The SAR Panel will monitor that all actions are completed from their own and the multi-agency action plan, and for ensuring that learning from the SAR is embedded in their organisation and constituent agencies. However, agencies should make every effort to capture learning points and take internal improvement action where possible while the SAR is in progress, rather than waiting for the SAR report and action plan. The SAR Panel will decide on appropriate time frames for each review action plan, this should not exceed 12 months for completion.
Publication of Review reports
In line with Schedule 2 of the Care Act, Salford SAB will include findings from any SARs in its annual report, and information on any on-going SARs. The annual report will list all completed SARs, the action taken or intended to be taken in relation to the findings, or where Salford SAB decided not to implement a recommendation the reasons for that decision.
Methodologies for SAR reviews
Traditional Serious Case Review model
This model is traditionally used where there are demonstrably serious concerns about the conduct of several agencies or inter-agency working and the case is likely to highlight national lessons about safeguarding practice.
This model includes The appointment of panel, including a Chair (who must be independent of the case) and core members who determine the terms of reference and oversee the process. Appointment of an Independent Report Author to write the overview report and summary report.
Involved agencies undertaking an Individual Management Review outlining their involvement, key issues and learning. Chronologies of events. Formal reporting to the Safeguarding Adults Board and monitoring implementation across partnerships. Publishing the report in full.
The benefits of this model are:
- It is likely to be familiar to partners.
- There is possible greater confidence politically and publicly as it is seen as a tried and tested methodology.
- It provides a robust process for multiple, or high profile/serious incidents.
The drawbacks of this model are:
- The methodology stems from the children's arena so the process is not so familiar to adult services.
- It is resource intensive.
- It is costly.
- It can sometimes be perceived as punitive.
- It does not always facilitate frontline practitioner input.
Action Learning Approach
This option is characterised by reflective/action learning approaches, which do not seek to apportion blame, but identify both areas of good practice and those for improvement. This is achieved via close collaborative partnership working, including those involved at the time, in the joint identification and deconstruction of the serious incident(s), its context and recommended developments. There is integral flexibility within this approach which can be adapted, dependent upon the individual circumstances and case complexity. There are a number of agencies and individuals who have developed specific versions of action learning models, including: Social Care Institute for Excellence (SCIE)-Learning Together Model. Health and Social Care Advisory Service (HASCAS). Significant Incident Learning Process (SILP).
Although embodying slight variations, all of the above models are underpinned by action learning principles.
The broad methodology:
- Scoping of review/terms of reference.
- Identification of key agencies/personnel roles.
- Timeframes:(completion, span of person's history).
- Specific areas of focus/exploration.
- Appointment of facilitator and overview report author.
- Production/review of relevant evidence.
- The prevailing procedural guidance.
- Summary of events and key issues from designated agencies via chronologies.
Material circulated to attendees of learning event, anticipated attendees to include:
- Members from SAB.
- Frontline staff/line managers.
- Agency report authors.
- Other co-opted experts (where identified).
- Facilitator and/or overview report author.
Learning event(s) to consider:
- What happened and why.
- Areas of good practice.
- Areas for improvement and lessons learnt.
Consolidation into an overview report with analysis of:
- Key issues.
- Lessons and recommendations.
- Event to consider first draft of the overview report and action plan.
Final overview report presented to Safeguarding Adults Board.
Agreed dissemination of learning, monitoring of implementation.
Follow up event to consider action plan recommendations.
Ongoing monitoring via the Safeguarding Adults Board.
The benefits of this model are:
- Conclusions can be realised more quickly and embedded in learning.
- Cost effective Partnership working and collaborative problem solving is enhanced.
- It encompasses frontline staff involvement.
- Learning takes place through the process, enhancing learning.
The drawbacks of this model are:
- Methodology less familiar to many.
- Events require effective facilitation.
- Specific versions such as SCIE Learning Together and SILP are copyrighted.
Individual Agency Review
This model would be relevant when a serious incident identifies single agency involvement or where potential one agency learning has been identified. There are no implications or concerns regarding involvement of other agencies and it is appropriate that lessons are learnt regarding the conduct of an agency and in the absence of rather than the need for a multi-agency review.Such reviews could be requested by the SAB.
If undertaken individually by an agency, the agency concerned should inform the Board they are undertaking an Individual Agency Review with a safeguarding element, in order for the Board to consider any transferable learning across partnerships.
Circumstances when this model might be appropriate:
- Serious Incidents - Implications relate to an individual agency but lessons could be shared, applied and learnt across the partnership.
- Where serious harm and/or abuse was likely to occur, but had been prevented by good practice (positive learning).
The benefits of this model are:
- Provides an opportunity for learning from an individual agency.
- Enables individual agency scrutiny into a specific area. Assists a 'Duty of Candour'.
The drawbacks of this model are:
- Can be seen as outside the SAR purpose of multi agency learning.
- Risks individual agency opposition.
Peer review approach
A peer review approach encompasses a review by one or more people who know the area of business and accords with self-regulation and sector led improvement programme. This approach is increasingly being used within Adult Social Care. Peer review methods are used to maintain standards of quality, improve performance and provide credibility. They provide an opportunity for an objective overview of practice, with potential for alternative approaches and/or recommendations for improved practice.
There are two main models for peer review:
Peers can be identified from constituent professionals/agencies from the Safeguarding Adults Board members.
Peers could be sourced from another area/SAB which could be developed as part of regional reciprocal arrangements, which identify and utilise skills and can enhance reflective practice.
The benefits of this model are:
- Increased learning and ownership if peers are from the SAB.
- Objective, independent perspective.
- Can be part of reciprocal arrangements across/between partnerships.
- Cost effective.
The drawbacks of this model are:
- Capacity issues within partner agencies may restrict availability and responsiveness.
- Skills and experience issues if SARs are infrequent.
- Potential to perceive peer reviews from members of a Board as not sufficiently independent, especially when they concern political or high profile cases.
Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is an investigation methodology used to understand why an incident has occurred. RCA provides a way of looking at incidents to understand the causes of why things go wrong. If the contributory factors and causal factors - the root causes - of an incident or outcome are understood, corrective measures can be put in place. By directing corrective measures at the root cause of a problem (and not just at the symptom of the problem) it is believed that the likelihood of the problem reoccurring will be reduced. This approach can help to prevent unwanted incidents and outcomes, and also improve the quality and safety of services that are provided. The RCA investigation process can help an organisation, or organisations, to develop and open culture where staff can feel supported to report mistakes and problems in the knowledge this will lead to positive change, not blame.
General principles of Root Cause Analysis:
RCA is based on the belief that problems are best solved by attempting to correct or eliminate root causes. To be effective, RCA must be performed systematically, with conclusions and causes backed up by evidence. There is usually more than one potential root cause of a problem. To be effective, the root cause analysis & investigation must establish ALL causal relationships between the root cause(s) and the incident, not just the obvious.
The benefits of this model are:
- The methodology is well known and frequently used in the NHS.
- Focus is on the root cause and not on apportioning blame or fault.
- Effective for single agency issues especially those related to NHS services.
The drawbacks of this model are:
- Requires skills and knowledge of RCA tools.
- Resource intensive.
Safeguarding Adults Review (SAR) Referral Form
- Cases should be referred to Salford's Safeguarding Adults Board SAR Panel for consideration if an adult at risk of abuse or neglect has died or been seriously harmed and abuse or neglect are believed to have been a factor.
- This form should be completed by anyone who has become aware of a case where the above criteria are met.
- All information provided should adhere to information sharing protocols - please note there is a statutory duty in Section 45 of the Care Act 2014 for agencies to share relevant personal data with the Safeguarding Adults Board.
- Please email this completed form to: email@example.com
- You will receive confirmation of your SAR referral form and be updated on the date that the referral is considered by the SAR panel and the outcome of the referral.
Purpose of a SAR
Learning lessons - 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.
It is vital, if individuals and organisations are to be able to learn lessons from the past, that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them. If individuals and their organisations are fearful of SARs their response will be defensive and their participation guarded and partial.
Its purpose is not to hold any individual or organisation to account. Other processes exist for that, including 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.
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