What is a Safeguarding Adults Review

Safeguarding Adults Reviews (SAR’s) are a statutory review process, under Section 44 of the Care Act 2014, for adults with care and support needs who have died or been seriously harmed through abuse or neglect. The review aims to find out what agencies did well and what they could’ve done better as a partnership.

The aim of the process is to learn lessons and make improvements, not to apportion blame to individual people or organisations.

A SAR is about promoting effective learning and improvement to prevent future deaths or serious harm occurring again.

Further information can be found in the Care and Support Statutory Guidance, Chapter 14, paragraphs 14.133 and 14.134.

More information on Safeguarding Adults Reviews and how they are undertaken across Cambridgeshire and Peterborough can be found in Cambridgeshire & Peterborough Safeguarding Adults Boards Safeguarding Adults Review Guidance

Referring a case for a Safeguarding Adults Review

Referring a case for a Safeguarding Adults Review: The referral form for a SAR can be found here: SAR Referral Form 2025 Completed forms should be returned to the Safeguarding Board Team Mailbox: safeguardingboards@cambridgeshire.gov.uk

IMPORTANT – do not use the SAR Referral form to make a safeguarding adult referral. To make a referral please visit Professionals – Making a Referral

There are three broad circumstances under which the Care Act 2014 legislation suggests a Safeguarding Adults Review may take place. The legislation makes a distinction between those circumstances where the SAB must or may arrange a SAR.

The SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if:

  1. There is reasonable cause for concern about the SAB, members of it or other persons with relevant functions worked together to safeguard the adult; and
  2. Either
    1. The adult has died and the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died; Or
    2. The adult is still alive and the SAB knows or suspects that the adult has experienced serious abuse or neglect

A SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs).

Published Safeguarding Adult Reviews

Review NameDate of PublicationLocal Authority AreaReview document linksThemes

Chris

9 February 2026PeterboroughChris SAR Executive Summary
  • Mental Health
  • Mental Capacity
  • Alcohol misuse
  • Self-neglect

Ben

19 January 2026PeterboroughBen Safeguarding Adults Review
  • Homeless / Rough Sleeping
  • Self-Neglect
  • Alcohol misuse
  • Mental Health
  • Mental Capacity

Jessica

19 January 2026CambridgeshireJessica Safeguarding Adults Review
  • Self-Neglect
  • Neglect
  • Carers Assessment
  • Mental Health
  • Mental Capacity
  • Non-Engagement

Norman

19 January 2026CambridgeshireNorman Safeguarding Adults Review
  • Mental Health
  • Self-Neglect
  • Hoarding
  • Domestic Violence

Joe

6 May 2025Cambridgeshire

Joe Safeguarding Adults Review

Joe SAR 7 Minute Briefing

  • Alcohol misuse
  • Self-neglect
  • Mental Capacity
  • Hospital Discharge

Patricia

6 May 2025Cambridgeshire

Patricia Safeguarding Adults Review

Patricia SAR 7 Minute Briefing

  • Hospital Discharge
  • Carers Assessment

Richard

6 May 2025Cambridgeshire

Richard Safeguarding Adults Review

Richard SAR 7 Minute Briefing

  • Self-neglect
  • Mental Capacity
  • Hospital Discharge
  • Domestic Abuse / Financial Abuse

Declan

4 October 2025CambridgeshireDeclan Safeguarding Adults Review
  • Learning Disabilities / Autism
  • Supported accommodation / commissioning
  • Mental Capacity
  • Brain Injury

Esther

2 December 2022Cambridgeshire

Esther Safeguarding Adults Review

Esther SAR Briefing

  • Substance misuse
  • Alcohol misuse
  • Domestic Violence
  • Coercion and control
  • Self-Neglect
  • Financial Abuse

Mark

2 December 2022Cambridgeshire

Mark Safeguarding Adults Review

Mark SAR Briefing

  • Mental Health
  • Mental Capacity
  • Brain Injury
  • Learning Disabilities
  • Medical Non-compliance

John

2 December 2022CambridgeshireJohn Safeguarding Adults Review
  • Alcohol misuse
  • Mental Capacity
  • Self-neglect

Miss Y

18 January 2022CambridgeshireMiss Y Safeguarding Adults Review
  • Supported accommodation
  • Mental Capacity
  • Mental Health

Carol

17 December 2021CambridgeshireCarol Safeguarding Adults Review
  • Mental Health
  • Learning Disabilities
  • Self-Neglect
  • Non-engagement
  • Mental Capacity

Simon

17 December 2021CambridgeshireSimon Safeguarding Adults Review Briefing
  • Mental Capacity
  • Neglect
  • Mental Health
  • Domestic Abuse / Coercive control
  • Financial Abuse

Dorothy

11 June 2021Peterborough

Dorothy Safeguarding Adults Review

Dorothy SAR Briefing

  • Self-neglect
  • Hoarding
  • Learning difficulties

Peter

16 November 2020Cambridgeshire

Peter Safeguarding Adults Review

Peter SAR Briefing

Peter SAR 7 Minute Briefing

  • Alcohol misuse
  • Substance misuse
  • Mental Health
  • Brain Injury
  • Homelessness
  • Self-Neglect
  • Mental Capacity
  • Hospital Discharge
  • No Recourse to Public Funds

Arthur

14 August 2019Peterborough

Arthur Safeguarding Adults Review

Arthur SAR Briefing

  • Self-neglect
  • Hoarding
  • Non-engagement

Katharine

11 June 2018CambridgeshireKatherine Safeguarding Adults Review
  • Self-neglect
  • Mental Capacity
  • Mental Health
  • Domestic Abuse

Care Home A

7 April 2016Peterborough

Care Home A Executive Summary

Care Home A Briefing

  • Organisational Abuse

Mrs MX

7 March 2016Peterborough

MX Safeguarding Adults Review

MX SAR Briefing