Safeguarding Reviews

With the implementation of the Care Act in April 2015, the Oxfordshire Safeguarding Adults Board now holds a statutory responsibility for the commissioning and undertaking of Safeguarding Adults Reviews (SARs). This page will hold all policies and procedure relating to the SAR process in Oxfordshire and published reports on any SARs completed through the Board. The referral form for a SAR can be accessed here: SAR Referral Form v4.

What is a Safeguarding Adults Review?

The overall purpose of a Safeguarding Adults Review is to promote learning and improve practice, not to re-investigate or to apportion blame. The objectives include establishing:

  • lessons that can be learnt from how professionals and their agencies work together
  • how effective the safeguarding procedures are
  • learning and good practice issues
  • how to improve local inter-agency practice
  • service improvement or development needs for one or more service or agency

Safeguarding Adults Reviews provide an opportunity to improve inter-agency working, for onward dissemination of lessons learnt to partner agencies, the sharing of best practice and ultimately better safeguarding of adults at risk of abuse or neglect.

A Safeguarding Adults Review is a multi-agency process that considers whether or not serious harm experienced by an adult, or group of adults at risk of abuse or neglect, could have been predicted or prevented and uses that consideration to develop learning that enables the safeguarding adults partnership in Oxfordshire to improve its services and prevent abuse and neglect in the future.

Referring a Case for Consideration

If a professional in Oxfordshire believes a case requires consideration by the Safeguarding Adults Board then they can complete the referral form below and submit it to the Board.

The criteria for a Safeguarding Adult Review are:

  • 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.
  • an adult has not died, but the professional knows or suspects that the adult has experienced serious abuse or neglect and there is concern that partner agencies could have worked more effectively to protect the adult.

In the context of SARs, 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.

Case Review Reports

Adult C – Published April 2018

The Oxfordshire Safeguarding Adults Board have published the following two documents in relation to the death of Adult C. It follows the conclusion of a Coroner’s inquest earlier this year (Feb 2018) which noted that the death of Adult C was likely to have been accidental, although it could not for certain be ruled out that it was a deliberate act.

Independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk

Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment.

Following publication of this report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England (South) commissioned a second report in June 2014 to find out whether there were wider commissioning, leadership or management issues that could have contributed to the inadequate care that Connor received.