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Safeguarding Adults Review library project proposes focus on systems learning

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The abuse or death of an adult receiving or in need of care rightly raises questions about whether the support they received could have been better and what can be learned to improve its provision in the future. Conducting Safeguarding Adults Reviews (SARs) became a statutory duty under the Care Act and – according to NHS Digital - 110 were carried out in 2016-17. But do SARs work to affect real changes?

Dr Lindsey Pike (RiPfA)

The SARs library project, commissioned by the Department of Health and Social Care (DHSC) and lead by Research in Practice for Adults (RiPfA) and the Social Care Institute for Excellence (SCIE), suggests that a focus on ‘systems’ rather than ‘case’ findings can help us ensure that SARs improve practice. Dr Lindsey Pike (RiPfA) and Dr Sheila Fish (SCIE) invite you to consider the possibilities of such an approach...

Dr Sheila Fish (SCIE)

Imagine a future where the SARs library exists…

"Greenside’s Safeguarding Adults Board manager is beginning a SAR about the death of a man who was homeless and had a longstanding alcohol dependency.

It’s important the SAR is proportionate. Resources are tight.

The Board wants to find out what has already been learned elsewhere and not reinvent the wheel.

They go to the SAR library site and find SAR Andrew, by Walthamstow Forest SAB, which describes a similar situation.

A crucial case finding from this SAR concluded that professionals continued to try to assess and treat Andrew’s physical condition even though it was clear his death was imminent.

A systems finding was identified: that there is there is no widely used care pathway, or allocation of role or responsibility for the palliative care of adults with longstanding alcohol/drug dependencies, who are terminally ill as a consequence of their addictions. This is what caused poor practice.

Greenside suspects this system finding applies to their area too, and uses this knowledge to refine their Terms of Reference so that the SAR will test out whether this, and other systems findings are evidenced locally."

From March 2018, we’re pleased to confirm that information like this will be easily available to those who need it.

What solutions will the library offer?

A vital function of the SARs library will be to enable the sharing of learning more widely. This means we need to be clear what kind of ‘learning’ we mean. Two different kinds of learning that SARs produce are:

  • Case findings – what were the individual examples of good or poor practice from the case. What was done well, or not?


  • Systems findings – examining the causes of those practice problems and successes. What helped or hindered the practice on a systemic level?

We want the SARs library to collate system findings, because this kind of learning is most useful for focusing improvement work.

Sharing systems findings in a national library will allow others to see if the causes of problems identified elsewhere exist locally, and readily identify causes that may be more effectively tackled at regional or national level.

The online resource will include a searchable library where Boards can categorise and upload their SARs and the learning within them. This means, in time, that we will need to agree some level of commonality for SARs about the kind of learning they produce and how it is presented.

Once agreed, this would need to be supported by SABs, by making expectations as explicit as possible in the commissioning process. We are developing SAR quality markers to help with this.

The workshops we’ve run so far have been broadly positive about taking this approach, and we are currently reviewing the feedback collected to make sure we listen and respond to comments and concerns.

How can you get involved?

Find out more about our evolving approach on a new open access website, to which we will be adding resources as they are developed and refined.

But for now, we are asking Boards to send in their published SARs for inclusion in the library. Check which SARs are already referenced here.

Further information

NHS Digital (2017) Safeguarding Adults Collection (SAC): England 2016-17 Experimental Statistics.

About Dr Lindsey Pike and Dr Sheila Fish

Lindsey Pike is an Associate for Research in Practice for Adults (RiPfA) and Sheila Fish is a senior research analyst and Head of Learning Together at the Social Care Institute for Excellence (SCIE). Together, they co-lead the SAR library project.

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1 comment

  1. Comment by Ian Hamer posted on

    Shared learning from outcomes has to be beneficial to all SAB's and the Library Project is an excellent medium through which shared learning can be achieved. However this should not be the only objective, it is to be hoped that the Library can contribute to policy development for future legislation in the are of adult social care.


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