Procedure for Safeguarding Adult Reviews

SARs are a vital mechanism for strengthening practice and improving outcomes across agencies. The (Care and Support Statutory Guidance, para 14.179) sets a clear expectation that SARs should be published unless there is a compelling reason not to, supporting transparency, accountability and the shared learning needed to prevent future harm.

In some reviews, publication may carry a risk of identifying the adult, their family or others involved. Where this risk cannot be managed through standard anonymisation, it may be appropriate to redact all references to the commissioning SAB. This approach enables the review to be included in the National SAR Library, ensuring that learning is still shared nationally while reducing the likelihood of local identification.

Publishing a redacted version preserves the core purpose of the SAR: promoting system-wide learning and improvement, while upholding necessary safeguards for privacy and anonymity. This maintains the balance between openness and protection and ensures that valuable insights continue to inform national practice development.

Publishing SARs helps to:

Disseminate learning widely: Making findings publicly accessible supports consistent improvement across health, social care and community services.

Maintain public confidence: Transparent publication demonstrates that safeguarding partners take serious incidents seriously and are committed to improvement.

Drive systemic change: Openly shared learning helps strengthen multi-agency collaboration and encourages better practice across organisational boundaries.

However, in exceptional circumstances—such as risks to privacy, potential distress to families, or ongoing legal processes—full publication may not be appropriate. In these reviews, the rationale should be clearly recorded, and learning should still be shared through internal or redacted mechanisms.

Ultimately, publication of SARs reflects a commitment to a culture of learning rather than blame. This approach ensures that safeguarding systems continue to evolve and that adults with care and support needs receive safer, more effective support.  More information can be found in section 24 of the Essential Guide to Safeguarding Adults Reviews (SAR).

Media and communication activity about the SAR will be co-ordinated by the City of York Council’s Communications and Media Department on behalf of the Board liaising with partners communication teams as appropriate.

The CYSAB must include the findings from any SAR in its annual report and include what actions it has taken, or intends to take, in relation to those findings. Where the CYSAB is unable to implement a recommendation then it must state the reason for that decision in the annual report. The CYSAB maintains a public record, actions and commentary to enable public accountability.

CYSAB will ensure that SAR publications will be submitted for inclusion in the national SAR library.

Where the recommendations for a SAR are linked to national issues and government policy, these will be escalated to the National SAB Chairs Network via the CYSAB Independent Chair. Any actions accepted by the national group will be updated on individual SAR action plans and agreed as completed locally pending any further instruction.