Safeguarding Adult Reviews

Safeguarding Adult Reviews (SARs) were previously known as Serious Case Reviews. They are held when an adult with care and support needs dies or suffers significant harm as a result of abuse or neglect.



Safeguarding Adult Reviews are not inquiries into how someone died or suffered injury, or to find out who is responsible.


  • look at any lessons we can learn from the case about the way professionals and agencies worked together
  • review the effectiveness of our safeguarding adults procedures
  • inform and improve practice
  • identify what can be done better to avoid a similar circumstance from reoccurring

The SAB aims to share learning from Safeguarding Adult Reviews widely: with local organisations and through the London and National Safeguarding Network across London and nationally.

When are they held?

Section 44 of The Care Act 2014 requires Safeguarding Adults Boards to undertake a Safeguarding Adult Review when specific criteria are met. This is when abuse results in the death or significant and possibly life-changing harm of an adult with care and support needs.

Read Government information about the Care Act 2014 and SARs.

Make a referral

Anyone may make a SAR referral, by completing the SAR referral form (MS Word, 17 KB) (MS Word, 17 KB). It is recommended that you refer to the SAR criteria contained in the SAB Richmond SAR Protocol 2018 (pdf, 1.6 MB).

Send your completed form by email to, or by post to:

Head of (Adult) Safeguarding
London Borough of Richmond upon Thames
Civic Centre
44 York Street

The SAR Subgroup usually makes a decision relating to any SAR referral within four weeks of receipt, and will inform the referrer of the decision made.

SAR reports and documents

View our local SAR Protocol 2018 (pdf, 1.6 MB).

The following reports explaining the outcomes of recent SARs have been anonymised. Any names and initials included in these documents are fictitous.


Updated: 28 February 2018