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Safeguarding Adult Reviews

The page provides information about process and findings of our published Safeguarding Adults Reviews (SARs).

Please note: This is not the same as raising a concern about an adult currently experiencing abuse or neglect. This needs to be referred to the local authority safeguarding team - you can find contact details here.

Cornwall and Isles of Scilly Safeguarding Adults Board has a locally agreed SAR framework that provides more detail about SAR criteria and process. There is also a leaflet to support families understanding of what a Safeguarding Adult Review is and what to expect. 

The Care Act 2014 places a statutory duty on Safeguarding Adults Boards (SABs) to 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 there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and condition 1 or 2 is met

Condition 1 is met if 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).
Condition 2 is met if the adult is still alive and the SAB knows or suspects that the adult has experienced serious abuse or neglect.

The purpose of a SAR process it not to apportion blame but to promote effective learning and improve how agencies work together to safeguard adults at risk. SABs look to review a case to identify what is helping and what is hindering safeguarding work, in order to remove barriers, promote good practice and protect adults from harm. 

Referral process:

Anyone can make a Safeguarding Adult Review referral by submitting a completed SAR referral form to  Please contact the team at if you need any further support.

The team will acknowledge receipt of the referral and be in touch to advise on next steps. 

Learning from SARs:

A national database of SAR reports published from 1st April 2019 has been compiled to maximise learning nationally. This is accessible to professionals and the public and has a search feature for key words to find reports relevant to location, types of abuse, care and support need and themes. The Local Government Association (LGA) also commissioned an Analysis of Safeguarding Adult Reviews April 2017-March 2019 to identify common themes. 

Professor Michael Preston-Shoot has recorded this short film and PowerPoint presentation of the findings. The full report is available at 

Below are the details of SARs undertaken by Cornwall and the Isles of Scilly Safeguarding Adults Board.






Joint Domestic Homicide Review (DHR)/SAR for Margaret -
published 26/01/2021


SAR for Jack -
published 27/11/2020
Morleigh Group SAR -
published 02/11/2020


Adult male, Paul, who died 2016, aged 70



Adult male who died 2013 -
Serious Case Review


Adult female who died 2008


Adult female who died 2007



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