Learning from Reviews

Safeguarding Adults Boards have a duty be assured that local safeguarding arrangements are in place as defined by the Care Act 2014 and statutory guidance.  Part of this duty is to carry out a Safeguarding Adult Review (SAR) when an adult at risk dies as a result of abuse or neglect, whether known or suspected, or is still alive but has experienced serious abuse or neglect and; there are concerns that partner agencies could have worked more effectively to protect the adult.

The purpose of a SAR is to promote effective learning and improvement action to prevent future deaths or serious harm occurring again. The aim is that lessons can be learned from a case and those lessons applied to future cases to prevent similar harm happening again.

The key themes arising from recent Walsall reviews were

  • The need to embed a person centred approach to practice,
  • Full compliance with the care act legislation and mental capacity act, including undertaking capacity assessments and recording the outcome
  • The need to continuously try to engage with service users who present as ‘non compliant’ or ‘difficult’
  • Quality monitoring of learning disability homes
  • Inter-local authority protocol when individuals are placed in the local area by another local authority
  • The need to undertake sound risk assessments for long term conditions

To ensure safeguarding practice is continuously improving and enhancing the quality of life of adults in its area, the Walsall Safeguarding Adults Board also undertake audits with agencies across the partnership who work with vulnerable adults. The group responsible for undertaking this work is the Multi-Agency Audits Group.   This sits as a sub group of the safeguarding board’s quality assurance and performance group and has a planned cycle of audit activity which is centred around the board’s priorities along with encompassing key learning from SARs and Learning Reviews.

During April—June 2018 the  theme for the deep dive cases was the multi-agency partnership response to Self-Neglect.  The audit highlighted  learning for partner’s understanding self –neglect  the audit also identified good multi-agency work and clear risk assessments. 

A key recommendation from the audits was consideration to adopt the Pan West Midlands policy and procedures on self-neglect including developing a pathway to follow with self-neglect cases.

Below are our published Serious Case Reviews:

SAR 1 Overview Report

SAR 2 Overview Report

SAR 3 Overview Report


The Safeguarding Board has produced a number of posters depicting the learning from recent reviews.

Learning from reviews

Capacity Poster   Unwise Poster

Abuse Poster   Cares poster

Consent Poster  Domestic poster