Cheshire East
Safeguarding Adults Board

Safeguarding Adult Reviews in Cheshire East

What Safeguarding Adult Reviews are

When an adult who needs care and support either dies or suffers serious harm, and when abuse or neglect is thought to have been a factor, Cheshire East Safeguarding Adults Board (CESAB) may need to review what has happened. This is called a Safeguarding Adults Review, or 'SAR' for short.

A SAR is a multi-agency review carried out to determine what agencies involved could have done differently that could have prevented harm or death from taking place.

The aim is not to apportion blame, it is to promote effective learning and improvement to prevent future death or harm occurring, and to improve how agencies work together towards achieving positive outcomes for adults and their families.

Anton Safeguarding Adults Review

Anton was Slovakian. He was 64 when he died. It is understood he had come to England 12 years previously. He had no family and appeared to be socially isolated. His understanding of the English language was poor. Anton had poor physical and mental health and was known to many services. Anton died of pneumonia in November 2021. This SAR examines issues around having limited English language, self-neglect, poor engagement with services and mental capacity.

Mervyn Safeguarding Adults Review

The following document identify learning and recommendations from the Safeguarding Adults Review for Mervyn, issues are focussed on self-neglect, non-engagement with services and fire risk

Professor Michael Preston-Shoot, Independent Author, discusses the learning and recommendations of the Mervyn Safeguarding Adults Review 

Jane Safeguarding Adults Review

The Safeguarding Adults Board commissioned a Safeguarding Adults Review following the death of “Jane”.

Jane was a 63-years old and had been diagnosed with Dementia in 2018. She lived in her own home and her husband was her main carer. Sadly, she was killed in an accident when she went missing from her home in December 2020

It should be noted that these events occurred during the early stages of the COVID pandemic when national lockdowns were established, placing restrictions on contact from family and professionals.

The Author has made 8 Recommendations to the Safeguarding Board. The Review also highlighted how COVID placed increased strain on carers, especially those caring for someone with a long-term illness such as Dementia. The pandemic also caused anxiety in accessing services particularly hospital or respite care, due to fear of separation or catching Covid. The Review highlighted the importance of Professionals utilising their Professional Curiosity including considering why people may initially be reluctant to accept support and how to strengthen knowledge about Dementia.

Discretionary Safeguarding Adult Reviews (D-SARs) 


CESAB can exercise discretion and arrange a Discretionary SAR in any case involving an Adult at risk in its area where it believes that there will be value in doing so. This may include where an agency believes there are lessons to be learned for all involved which will improve multi agency working, practice and information sharing.

A D-SAR will -

  • Highlight areas of good practice to be shared
  • Identify how and within what timescales any actions will be acted on, and what is expected to change.
  • Contribute to a better understanding of the nature of Adult Safeguarding
  • Ensure, when appropriate, that the experiences of the service user and their family are heard regarding their lived experiences and the impact of adult abuse/ and neglect.

Each D-SAR will result in a 7-minute briefing, this report will provide the key themes and recommendations surrounding the review. The expectation is that team leaders across the multi-agency will present these briefings to their staff, on a regular basis.

Case AD 

This DSAR focuses on the assault and neglect of a 90yr old female allegedly by her 50-year-old son. Her son was main carer to AD. AD has full capacity but has mobility issues, the case focuses on neglect, physical abuse, and carer stress/issues

7 Minute Briefing AD (PDF, 484KB)

Case Mr & Mrs YZ 

This DSAR focuses on the physical assault of Mr and Mrs YZ by their son, the case focuses on financial abuse and professional curiosity.

7 Minute Briefing Mr & Mrs YZ (PDF, 783KB)

Case AB 

This DSAR focuses on self-neglect, alcohol misuse and repeated missed appointments with professionals. It is important to note that this case took place during Covid-19 lockdown.

7 Minute Briefing AB (PDF, 789KB)

Case Mr C

This DSAR focuses on Mr C who died from self-injury due to extensive fire burns. The case focuses on dementia, mental capacity, and carer stress.

7 Minute Briefing Mr C (PDF, 488KB)