Welcome to the Keeping Bristol Safe Partnership website.

Safeguarding Adult Reviews

A Safeguarding Adult Review (SAR) is a multi-agency review required by The Care Act (2014) and conducted by a local Safeguarding Adults Board (SAB). In Bristol, the Keeping Bristol Safe Partnership fulfil the function of the local Safeguarding Adults Board.

As stated in section 44 of The Care Act (2014), a SAR must take place when:

14.122. SABs must arrange a SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.

14.123. SABs must also arrange a SAR if the same circumstances apply where an adult is still alive but has experienced serious neglect or abuse. SABs are free to arrange for a SAR in other situations where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults, and can include exploring examples of good practice.

SABs may also arrange for a SAR in any other situations involving an adult in its area with needs for care and support. (The Care Act 2014, s14.134).

A Safeguarding Adults Review (SAR) is a multi-agency review process which seeks to determine what agencies could have done differently that could have prevented harm or a death from taking place. The purpose of a SAR is to promote effective learning and improvement, not to apportion blame.

The Keeping Bristol Safe Partnership is responsible for the commissioning of Safeguarding Adult Reviews and conducts SARs in accordance with the KBSP SAR Protocol (2017).

If you believe that a case meets the criteria for SAR, please complete a SAR Request Form and email to KBSP.statutoryreviews@bristol.gov.uk. You will need to demonstrate how the criteria are fulfilled and provide as much information as possible to support this.

Before submitting the referral do discuss with your agency representative on the KBSP SAR/DHR sub group. If you do not have a representative please discuss with the adult safeguarding lead in your organisation. If you are unsure if your organisation has a representative on the KBSP SAR/DHR sub group, contact KBSP.statutoryreviews@bristol.gov.uk and the business unit will be able to advise you.

Brian, 81, was paralysed from the waist down and also experienced a number of complex health conditions. Brian relied on visiting carers and his son, Alan, who he lived with and who was his primary caregiver. A number of organisations had contact with Brian or were involved in his support plan over the years. In August 2021, Brian tragically died at home.

Joanna was a woman in her 30s. She had a learning disability and lived independently in Bristol. A Safeguarding Adults Review (SAR) was commissioned by the Keeping Bristol Safe Partnership (KBSP) after a series of incidents in which Joanna experienced serious physical, sexual and financial abuse.

This joint Safeguarding Adult Review (SAR) and Domestic Homicide Review (DHR) looked into the experiences of Caroline (not her real name) who died in 2018. The full review has not been published to protect Caroline’s identity. A learning brief has been published to ensure the learning from this review can be shared with professionals.

This Safeguarding Adults Review looked at the experiences of two adults, Charles and Bridget (not their real names) who died in early 2021. Charles and Bridget died in separate circumstances, however the partnership recognised that self-neglect was a theme in both cases and commissioned a thematic review.

Martyn was a 25 year old man with mild learning disabilities and foetal alcohol spectrum disorder. He tragically died in October 2018. Video evidence from the hours prior to his death showed that he had been the subject of abuse whilst intoxicated. The cause of death could not be definitively linked to the abuse that Martyn experienced. The themes of mental capacity, mate crime, substance misuse, social isolation and meaningful activity have been explored in this SAR.

Kamil was a Kurdish asylum seeker who was murdered in 2016 by Mr X, a white British male, whilst both were residents in the same supported living accommodation for individuals with mental health needs.

The Bristol Safeguarding Adults Board commissioned a Safeguarding Adults Review into the circumstances surrounding the death of Christopher. He was admitted to hospital after becoming ill and losing significant weight as a result of refusing food and medication in his supported living provider’s care.

The BSAB agreed that a joint Thematic Review with the Safer Bristol Community Safety Partnership should be undertaken to ascertain whether there were practice issues in this instance and/or opportunities for development in the protection of adults in the city in this area.

This Serious Case Review was commissioned by Bristol Safeguarding Adults Board (BSAB) following the death of Melissa in October 2014 after being killed by a fellow resident in a Care Home.

Mr C, aged 61, died in a fire at his flat in Bristol in 2014

The Bristol Safeguarding Adults Board (BSAB), commissioned a Serious Case Review (SCR) following the death of a 47 year old man called Simon.

The RC Adult Serious Case Review followed the death of RC in August 2013 after being killed by a fellow resident in supported accommodation.