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Safeguarding Adults Review Reports


Birmingham Safeguarding Adults Board (2012) A Serious Case Review in Respect of A2 – death of a man with complex needs.

Bristol Safeguarding Adults Board (2017) Serious Case Review: Following the murder of a young adult, ‘Melissa’, 18 years old, in October 2014 – which identified problems with transition from children’s to adults’ services, risk assessments, and out of area placements.

Cornwall Adult Protection Committee (2007) The Murder of Steven Hoskins – murder of a man with learning disabilities.

Kent and Medway Safeguarding Vulnerable Adults Executive Board (2013) Executive Summary of a Serious Case Review: Mr J – death of a man, where concerns of exploitation and physical abuse.

Plymouth Safeguarding Adults Board: Safeguarding Adults Review – Ruth Mitchell (2017) – woman with mental health problems, who died of malnutrition.

Rochdale Safeguarding Adults Board: Safeguarding Review regarding ‘Tom’ (2017) – murder of a man in his home, who had a long history of alcohol problems and was being exploited by his associates.

South Gloucestershire Safeguarding Adults Board (2012) Winterbourne View – abuse by staff at hospital for adults with autism and learning disabilities.

Surrey Safeguarding Adults Board (2013) The Death of Mrs Gloria Foster – death of an elderly woman following withdrawal of service as result of sudden closure of home care agency.

Verita (2014) Independent investigation into the death of CS – a report for Southern Health NHS Foundation Trust into the death by drowning of a young man with epilepsy.

Warwickshire Safeguarding Adults Partnership (2010) The Murder of Gemma Hayter – murder of a woman with learning disabilities.

West Sussex Safeguarding Adults Board (2014) Orchard View SCR – closure of Southern Cross Healthcare care home for people with old age and dementia; the Coroner found issues of institutional abuse and neglect contributed to the deaths of five residents at their inquests.


Learning from SARs: A Report for the London Safeguarding Adults Board (Braye and Preston-Shoot, 2017)

A Decade of Serious Case Reviews, Hull Safeguarding Adults Partnership Board, 2014