Published SARs

19th September 2023:

This is a combined review which brings together the requirements of a Domestic Homicide Review (DHR) and a Safeguarding Adults Review (SAR) into the circumstances of the deaths of Kimmi and Alfred.


21st NOVEMBER: Essex Safeguarding Adults Board (ESAB) is publishing six Safeguarding Adults Reviews (SARs). Publication was delayed owing to the unprecedented pressures created by the Pandemic on the health and social care system, both in Essex and nationally, consequently ESAB proactively decided to pause our review processes in recognition of the demands faced by front line services and practitioners. Full narrative document can be found here.

Upon review of the recommendations contained within these six SARs, there are five common themes which have been outlined within this document

The Five Themes from 6 x SARs

  • Theme 1: Challenges when working with those who experience Complex Needs
  • Theme 2: Improving Making Safeguarding Personal (MSP) and hearing the voice of the adult at risk
  • Theme 3: The importance of a shared approach to setting high standards in safeguarding practice and oversight from ESAB
  • Theme 4: ESAB’s oversight of outcomes from partner’s quality assurance of safeguarding systems
  • Theme 5: Improving interagency communications between Health and Social Care

The development and delivery of action plans that enable the learning identified through the reviews will be monitored by ESAB and its multi-agency partners.

2022 SAR Report - 'Lucy'

This Safeguarding Adults Review (SAR) was commissioned by Essex Safeguarding Adults Board following the death of Lucy an 87-year-old lady at Basildon University Hospital NHS Trust on 28 April 2020. It considers the care provided to Lucy following a fall at home, in Essex on 21 February 2020, and the effectiveness of inter-agency collaboration, communication and information sharing throughout her care.

2022 SAR Final Executive Summary - 'Miss J'

Miss J died, at the age of 20, on the 5th February 2020, at a Hospital in Essex. She had been admitted to the Hospital after tying a ligature whilst an inpatient at Private Mental Health Hospital 1, Essex. This is a secure psychiatric hospital for people who present a risk to themselves and/or other people.

The present Safeguarding Adults Review (SAR) considered the way in which
professional agencies involved in Miss J’s care worked to address her clinical needs and protect her from abuse and harm. The primary focus of the SAR is on events which occurred from October 2016 until her death in February 2020.

2022 SAR Report - 'Sonia'

This report outlines the process undertaken by the Essex Safeguarding Adults Board in reviewing the period of care prior to the death of Sonia.

Sonia died in September 2017, aged 60. She lived with her brother, who also had care and support needs. The cause of Sonia’s death was given by the coroner as “natural causes (1) DeepVein Thrombosis (2) Pulmonary Embolism.

2022 SAR Report - 'Simon'

In July 2021, the Essex Safeguarding Adults Board considered the case of Simon who had been found deceased in his home. Simon was known to a number of services and was being supported at the time of his death. The safeguarding board recognised the potential to improve the way agencies
worked together and commissioned this Safeguarding Adults Review (SAR).
The review aimed to use the experiences of Simon to identify learning and to continually improve the way that agencies support the wellbeing of adults at risk. A wide number of agencies from the safeguarding partnership took part and four key findings were identified.

2022 SAR Report - 'Megan'

Megan had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and attention deficit hyperactivity disorder (ADHD). She had been known to Essex Partnership University Trust (EPUT) since 2015 both as an inpatient service user, to several different psychiatric wards, and within community mental health settings.