Toggle Contrast

Safeguarding Adult Reviews

What is a Safeguarding Adult Review?

The SAR aims to learn lessons from an incident that will prevent deaths and serious abuse or neglect happening in the future. SARs are also used to explore examples of best practice in the way the case was managed, for example how agencies worked together to prevent and reduce abuse and neglect.  Under the Care Act 2014, only Safeguarding Adult Boards (SAB) can carry out a SAR.

The Act specifies at section 44 that a SAR must be conducted in circumstances where the CSAB has concerns about how members of CSAB or other agencies with relevant functions, have worked together to protect an adult in Croydon, with care and support needs, who:

  1. has died as a result of abuse or neglect (whether known or suspected), or
  2. is still alive and is know (or suspected) to have experienced serious abuse or neglect.

Anyone can request a SAR

  • The adult who has experienced abuse or neglect,
  • Their family, friends or advocate,
  • An organisation that has worked with the adult,
  • Any organisation that is a member of the Safeguarding Adults Board,
  • MP, councillor, or
  • Coroner.

For more information on SARs, read the Croydon SAR Framework or contact the CSAB Manager on note: The SAR Framework is currently being updated and a revised version will be published shortly.

The SAR Sub group meets every eight weeks; dates of forthcoming meetings are set out below, along with deadlines for receipt of SAR Request forms.  (Request form available here: SAR Request form – version updated 12.07.21).

Safeguarding Adult Reviews [SARs]

Anthony Published 9 May 2024

Anthony was a 58 year old black British man who completed suicide in July 2021.   Anthony had been a successful business and family man for most of his life.  He had a partner with whom he had two children.   He was also an owner of his own business.  His family described his mental health problems as having started around 15 years prior to his death.   Some of the key learning from the review was around ongoing support received at points of transition of care; the interface between safeguarding and mental health; support for the family; use of Mental Capacity Act and clear leadership in the care of complex clients.

Final Anthony SAR report May 2024

Anthony 7 minute briefing May 2024


Ben Published 5 September 2023

Ben was in his late 30s when he died.  He was well-educated and had been active in local politics.  This SAR raised issues around self-neglect, mental capacity and executive function, information-sharing and discharge to “no service”.

Ben Final Report

Ben 7 Minute briefing


Sylvia Published 4 May 2023

Sylvia was a 19-year-old British Sri Lankan woman who was known for her smile, charm, love of dancing, and artistic expression. Her youth worker described her as a “beautiful soul” and provided support to her throughout her youth.  A Safeguarding Adult Review (SAR) was undertaken by Croydon Safeguarding Adult Board in collaboration with both Bromley and Kingston Safeguarding Adult Boards.  The SAR was commissioned after Sylvia was tragically found dead in September 2021, of a suspected drug overdose and we are keen across all three Boards to share the learning from this review widely.

Sylvia Final Report pdf

Sylvia SAR – 7 Minute Briefing – Feb 2023


O1  Published June 2022

O1 SAR Final Report

O1 7 Minute Briefing

Madeleine Published March 2022

Madeleine had a diagnosis of Autistic Spectrum Disorder, ’emotional dysregulation’ and Obsessive-Compulsive Disorder.  She was well known to many services and had a long history of mental health support from a very young age.  Madeleine was of mixed ethnicity (White British/Black Nigerian) and she was 18 years old when she died.  She was found suspended from her door at her accommodation and later died in hospital.

Madeleine SAR Final Report 

Madeleine 7 Minute Briefing

Duncan Published March 2022

Duncan died at the age of 35, he was White British and had fallen from a building with the cause of death regarded as a possible suicide.  Duncan experienced periods of homelessness and living in hostels and was known to misuse substances and there is a history of concerns about suicidal ideation.  He had longstanding mental health problems with several hospital admissions with various diagnoses recorded including paranoid schizophrenia.

Duncan SAR Final Report

7 min briefing Duncan

Mr Hong Published March 2022

Mr Hong came from the People’s Republic of China and was a failed asylum seeker in the UK, where he had been living on his own for 17 years.  His first language was Mandarin and he had limited use of English.  Mr Hong was 59 years old when he died; he killed himself by hanging using the alarm pull cord in his room at his nursing home.

Mr Hong SAR Final Report

Mr Hong 7 Minute Briefing

Mr Hong 7 Minute Briefing audio version:

Download Mr Hong 7 Minute Briefing audio version (MP3)

Catherine SAR Published October 2021

The CSAB are today publishing a Safeguarding Adult Review into the death of Catherine and the Board would very much like to thank the support and engagement from family members and friends.  They worked with the board and the report author throughout the process and offered their support going forward to ensure lessons are learned from this review.

Catherine died at 85 years of age and was found in her own home after police entered her property.  Catherine was born in Ireland before moving to England and was widowed in 2002.  Her first contact with Mental Health services was in 1974 when she had a diagnosis of Paranoid Schizophrenia with further contact with mental health services between 2002 – 2011.

The report makes 16 recommendations in order to make improvements across the partnership and to share learning from this review.  An Action Plan will be developed and the progress monitored by the CSAB SAR Sub group.  Click below for the full report and the 7 Minute Briefing.

Catherine SAR Final Report

Catherine 7 Minute Briefing

VB SAR Published June 2020

The Croydon Safeguarding Adult Board recently published a Safeguarding Adult Review into the death of VB and the Board wishes to record their thanks to her family for their assistance throughout and after the review process.

Valerie was 79 years old when she died.  She was born in India and moved to England at the age of 10, she became a teacher and moved to London where she taught until 1992.  She was married for 45 years until the death of her husband in 2003.  She owned and lived in a 4 bedroom house in Croydon and although a large house it had many memories and couldn’t cope with the stress of moving.  VB suffered from significant mental health issues and disengaged from mental health services, her GP and her family.

The report makes twelve recommendations to support improvements across agencies to protect those who are at risk of abuse or harm and embed learning across the partnership.  The full report can be found below along with a 7 Minute Briefing, an Action Plan to be published shortly.

VB SAR Final Report

VB 7 Minute Briefing


A1 SAR Executive Summary Published March 2016

CH 7 Minute Briefing produced following a multi-agency workshop .



Date of 2024 Meetings

Request Form to be submitted by:

17 January 3 January
14 March 29 February
8 May 24 April
10 July 26 June

To raise a concern about abuse or neglect, please use the online form.