Second national analysis of SARs published

Front cover of Second national analysis of safeguarding adult reviews

Introduction

Safeguarding isn’t just a process—it’s the heart of good care. The latest Second National Analysis of Safeguarding Adult Reviews (2019–23) shines a spotlight on what we’re doing well and, more importantly, where things still go wrong. With over 650 reviews analysed, the findings reveal recurring themes—self-neglect, missed opportunities, weak risk management—that every care worker, manager, and leader can learn from. This isn’t about statistics; it’s about real people whose lives depended on us noticing, acting, and working together.

Second National Analysis of Safeguarding Adult Reviews

Purpose & Scope
The review was conducted by Partners in Care and Health (LGA and ADASS) and examines learning from 652 Safeguarding Adult Reviews (SARs) carried out between April 2019 and March 2023—a period that includes the COVID-19 pandemic. 229 of these SARs were considered in more detail. It builds on an earlier analysis from 2017–19, supporting a growing understanding of adult safeguarding in England.

Key Findings (2019–23)

Types of Abuse/Neglect

·        Self‑neglect is the most common issue, appearing in 60% of cases—up from 45% previously.

·        Neglect/acts of omission present in 46% (up from ~37%).

·        Other increases: domestic abuse (10% → 16%), discriminatory abuse (1% → 2%), sexual exploitation (2% → 4%).

·        Decreases noted in physical abuse (19% → 14%), psychological abuse (8% → 4%), and organisational abuse (14% → 4%).

Profiles of Individuals

·        The SARs covered 861 individuals.

·        Age varied widely, with self-neglect most common among those in mid-life, while sexual or modern slavery issues were more common in younger people.

·        Mental ill health (72%) and chronic physical health conditions (63%) were prevalent, along with rises in substance misuse (46%) and impaired mobility (27%).

·        Most individuals lived alone (47%)—abuse mostly occurred at home (73%).

Learning from Practice – 229 SARs subject to detailed review.

Direct Work

·        Good Practice: Risk assessment, person-centred approaches, recognition of abuse, continuity, attention to health needs (seen in ~21–31%).

·        Shortcomings (much higher frequency): Poor risk management (82%), inadequate mental capacity considerations (58%), lack of personalised approaches (50%), weak professional curiosity (44%).

Interagency Working

·        Good examples: 24% noted effective communication across agencies; 23% mentioned cross-agency coordination.

·        However, serious weaknesses included poor coordination (72%) and information-sharing (70%).

Organisational Support & Governance

·        Positive examples (e.g. supervision, policies) were rare (each under 3%), while shortcomings were prevalent—management oversight (31%), training gaps (23%), and poor policies (28%).

Why It Matters

This analysis reveals that safeguarding adults requires a whole-system focus: not only attentive frontline practice, but robust interagency coordination, organisational support, governance clarity, and national policy alignment. Self-neglect has emerged as the most prevalent concern, highlighting the importance of nuanced responses that recognise both named and hidden forms of harm.

Conclusion

The message is clear: safeguarding must be everyone’s business, every day. Whether you’re supporting someone in their own home, running a care service, or coordinating with health colleagues, the lessons from these reviews are practical and immediate—be curious, share information, and put the person at the centre. Change doesn’t always come from national policy; it starts with what we do on the ground. By learning from these SARs, we can turn missed chances into better outcomes, and make sure the people we support live with dignity, safety, and trust.