Safeguarding Adult Reviews

Under the Care Act 2014, the Board is responsible for the coordination of Safeguarding Adults Reviews (SARs). These reviews are commissioned where there has been an incident of serious harm or death involving a vulnerable adult. A multi-agency process, SARs aim to identify where agencies or individuals might have been able to act differently and this learning is implemented to try and prevent serious harm or death from happening again.

Safeguarding Adults Reviews that have been published in Lambeth

SARs in Lambeth will be published here:

SAR HIJ - SAR H, I and J was a thematic Safeguarding Adults Review examining three cases with shared characteristics, enabling learning about common risks, system responses and opportunities for improvement across agencies.
 
Themes: Self Neglect & Mental Health 

Mr A - was a Serious Case Review carried out before the introduction of the Care Act; we have shared this 7-minute briefing as we feel the learning is still relevant.

Themes including Mental Health and Homelessness

SAR D - themes including Self Neglect and Physical Health
SAR E - themes including Substance Misuse and Self Neglect
SAR Martin- themes including Substance Misuse and Self Neglect
SAR Yi - themes including Mental Health and Homelessness.  This SAR was undertaken jointly with Safeguarding Adult's Boards for Newham, Islington, Hackney and Lambeth
SAR G - themes including Learning Disability and Neglect

Safeguarding Adults Review (SAR) Subgroup

The Safeguarding Adults Review (SAR) Subgroup sits under the Lambeth Safeguarding Adults Board (LSAB) and plays a key role in ensuring the Board meets its statutory duties under the Care Act 2014.

The subgroup oversees the identification, commissioning, and scrutiny of Safeguarding Adults Reviews where there are concerns about how agencies worked together to safeguard an adult who has died or experienced serious harm.

Its core focus is on learning and improvement. The subgroup brings partners together to review complex cases, identify what could be done differently, and ensure that learning is shared across agencies and leads to tangible change in practice.

Through this work, the subgroup strengthens multi-agency collaboration, promotes reflective learning, and helps drive improvements in how services work together to protect adults at risk in Lambeth.

 

Lambeth Safeguarding Adults Review (SAR) Protocol

The Lambeth Safeguarding Adults Review (SAR) Protocol sets out how SAR referrals can be made to the Board and how those referrals are managed. 
 
Any professional, agency or individual can submit a referral, although these should usually be agreed within the relevant organisation and supported by a senior manager. Referrals are made using the SAR referral form and should clearly explain how the case meets the S44 SAR criteria (Care Act 2014) or why a review would add learning. Once received, referrals are screened and considered by the SAR Subgroup, who will review the information, may seek further clarification, and make a recommendation on whether a SAR or another form of review should take place. 
 
The final decision is made on behalf of the Board, and feedback is provided to the referrer. Where a review is agreed, a structured process is put in place to examine the case, involve partners and family members where appropriate, and ensure that learning is identified, shared and translated into clear actions to improve practice across the partnership.
 
The LSAB SAR PROTOCOL was updated in November 2025 following the introduction of the updated Pan London Multi Agency Safeguarding Policy & Procedures Document.