The SAR is a statutory learning-focused process, designed to have practical value by illuminating barriers and enablers to good practice, untangling systemic risks, and progressing improvement activities.
The purpose of a SAR is to determine where multi-agency working went well and what might have been done differently that could contribute towards preventing similar harm or death reoccurring in the future. It therefore requires outcomes that:
The purpose of the review is not to identify or apportion blame or hold any individual or organisation to account as other processes exist for this, including coronial procedures, criminal proceedings, disciplinary procedures, employment law and professional regulation.