Learning from Safeguarding Adults Reviews: How can they have national impact?
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Adi Cooper and Professor Michael Preston-Shoot provide an update on recent developments concerning how issues from Safeguarding Adults Reviews (SARs) can be escalated nationally.
Recently there has been some significant progress following a review by the Department of Health and Social Care (DHSC) and the National Network for SAB Chairs of whether the safeguarding escalation process was achieving change and the greater oversight of learning from reviews expected from the newly established National Adult Safeguarding Board.
Safeguarding Adults Boards (SABs) have been commissioning Safeguarding Adults Reviews for more than 10 years to disseminate learning from tragic events about how multi-agency working can improve safeguarding adults. It is critical for family members and friends of the people who have died or been seriously abused that we demonstrate positive impact, improvement and change.
Independent SAR authors have focused on recommendations for local partners’ and systems’ learning, with some authors identifying gaps in national legislation and policy that need rectifying to support desired changes. Individual SARs occasionally have had national exposure[1], stimulating outrage and national work across key agencies to achieve change, however, there was no routine mechanism for escalation; this was a significant gap.
In 2020, SAB Chairs and DHSC colleagues developed the national escalation protocol for SAR recommendations to provide a pathway for escalation of recommendations from SARs that required a national response. The protocol sets out the SAB Chair presents the SAR and the relevant recommendations (the issue for national escalation) to the regional SAB Chairs group and then to the National SAB Chairs meeting. This is to gather evidence (from other SARs) that the issue is not specific and local, but more widespread and warrants escalation. The use of the national escalation protocol for SAR recommendations however has been intermittent and the Government response has been uneven.
This year, DHSC has established an internal ‘SAR recommendation Challenge Group’ to help the process become more effective. This group, which meets quarterly, reviews the SAR recommendations that have been escalated through the national SAB Chairs Network as well as the Government’s draft responses to see how effective they are in supporting improvement and change. Membership of the group includes SAB Chairs, CQC, PCH, NHSE and MHCLG.
Experience from the first two meetings of the SAR challenge group in May and June 2026 has demonstrated that SAR authors need to be clearer about what they are escalating and why. SABs (through SAB Chairs) need to be able to demonstrate at regional and national levels a clearer and smarter proposition for why a particular issue should be escalated.
The escalation protocol has been revised and a pro forma developed to support the improved process – these are now being tested out and may change over time as the role and responsibilities of the National Safeguarding Adults Board are being developed. In the process of reviewing and updating the Care and Support Statutory Guidance on safeguarding adults, the effectiveness of SARs in driving change and improvement will be considered. Are the current arrangements good enough?
Safeguarding risks have changed over time and we are identifying new risks. What did we understand ten years ago about cuckooing (home invasion) which is now a criminal offence? Safeguarding adults work will continue to evolve and the escalation protocol used to raise awareness of new areas of risk.
What remains key is that learning from SARs about gaps in law and/or policy prompt action at a local and national level. We must continue to improve how we do this to ensure that mechanisms are embedded as business as usual and to demonstrate a learning culture that will prevent safeguarding risks and protect people from abuse and neglect.
Adi Cooper is an ADASS Associate and an ADASS/LGA: Partners in Care and Health Safeguarding Adviser.
Professor Michael Preston-Shoot is a Joint Convenor National Network for SAB Chairs.
[1] For example Winterbourne View and Whorlton Hall