One of the core duties is that Safeguarding Adults Boards must arrange and undertake Safeguarding Adults Reviews when the criteria is met in accordance with s44 Care Act. The multi-agency Doncaster Safeguarding Adults Board (DSAB) has the lead responsibility for agreeing and conducting a Safeguarding Adults Review (SAR), previously known as a serious case review/lessons learned reviews.

Doncaster Safeguarding Adults Board values itself for being open and transparent, and proactive in learning from Safeguarding Adults Reviews to ensure that the Partnership develops and uses a positive reflective practice approach to inform the development and assurance of safeguarding adults work in Doncaster. Safeguarding Adults Reviews are essential in helping the Board prevent abuse and neglect of adults at risk and learn from cases and situations that challenge us as a multi-agency partnership.

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A SAR should be considered when:

  • An adult in its area dies as a result of abuse or neglect, whether known or suspected


  • there is concern that partner agencies could have worked more effectively to protect the adult.


  • 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.  E.g. 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 of neglect.

Enquiries into how an Adult at Risk died or who is to blame is a matter for coroners and criminal courts to determine.

The purpose of having a Safeguarding Adults Review/Lessons Learned Review is:

  • To seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. 
  • To identify lessons that can be learned from the case and applying those lessons to prevent similar harm occurring again.

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Last updated: 07 March 2022 13:47:14

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