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Safeguarding Adult Reviews

The Care Act 2014 states that Safeguarding Adult Boards have a statutory responsibility to arrange a Safeguarding Adult Review (SAR) when an adult dies as a result of abuse or neglect (whether known or suspected), where there is concern that partner agencies could have worked more effectively together to protect the adult. The overall purpose of a SAR is to promote learning and improve practice. It is not to re-investigate or to apportion blame.

You can find each of the SARs and Learning Reviews published in the last 12 months below. SARs and Learning Reviews published prior to this can be found on the next page.

Safeguarding Adults Review in respect of Tom (October 2024)

At the time of publication of this report, Tom is 41 years of age and refuses to be defined by his disabilities. He has a diagnosis of cerebral palsy, complex postural needs, and has a sight impairment. Tom requires a carer to be available 24 hours a day and uses a motorised wheelchair at all times. Tom is currently living in his own accommodation in Chichester, after living in an emergency place of safety, a residential care service, since August 2020.

Prior to his move, Tom lived in the community with his now ex-wife and his live-in carer. From 2016, Tom began to experience neglect and emotional/psychological abuse by his then wife, and paid carer. The abuse and neglect became significantly worse over time, and Tom became isolated from his family and friends. In 2020, Tom’s friend became concerned about Tom’s circumstances, following contact from Tom. This led to Tom’s friend contacting Tom’s mother, who subsequently made a safeguarding referral to West Sussex County Council.

Key documents:

Meta-analysis of Safeguarding Adults Reviews featuring self-neglect (June 2024)

This meta-analysis was commissioned by the West Sussex Safeguarding Adults Board. East Sussex Safeguarding Adults Board and the Brighton & Hove Safeguarding Adults Board contributed to the meta-analysis by providing Safeguarding Adult Reviews (SARs) for analysis, and by being part of the review panel.

This analysis includes the circumstances of two adults who were referred to the Board; IL and TB, who both had a history of self-neglect. At the point of referral for IL and TB it was agreed that, although individually both cases met the criteria for a SAR, there was a need for wider learning regarding self-neglect within Sussex as a whole. To do this, a thematic analysis of findings from recent SARs involving self-neglect was commissioned to consider changes to practice, process, policy, and procedure.

Key documents:

Last updated: 09 June 2025