skip to main content


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.

Bristol – Safer Bristol Partnership: Multi-Agency Learning Review Following The Murder of Bijan Ebrahimi, an Iranian man who was murdered after suffering years of harassment and abuse.

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