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Below are links to key Safeguarding Adult Review reports and Inquiry Reports, in order of publication with most recent first:

Safeguarding Adult Reviews

Norfolk Safeguarding Adults Board Safeguarding Adults Review (SAR) into the deaths of Joanna, “Jon” and Ben (2021). They had learning disabilities and had been patients at Cawston Park Hospital in Norfolk. They died between April 2018 and July 2020. The review made 13 recommendations for critical system / strategic change.

City and Hackney Safeguarding Adults Board Safeguarding Adult Review into Death of Jo-Jo (2019) The review found the Council breached the Care Act 2014 by failing to properly assess a disabled woman who died following complications related to scabies.

Bournemouth and Poole Safeguarding Adults Board Safeguarding Adult Review and Poole Community Safety Partnership Domestic Homicide Review (2019) into the death of ‘Harry’, aged 22, who had global developmental delay, a moderate learning disability and autistic traits. He was  murdered by two people, one of with whom he had a relationship.

Barking and Dagenham Safeguarding Adults Board (2018) Safeguarding Adults Review Overview Report ‘Drina’ into apparent failure to safeguard Drina, a vulnerable 35 year old Romanian female with learning disabilities.

Newcastle Safeguarding Children Board and Newcastle Safeguarding Adults Board (2018) Joint Serious Case Review Concerning Sexual Exploitation of Children and Adults with Needs for Care and Support in Newcastle-upon-Tyne

Bristol Safeguarding Adults Board (2018) Safeguarding Adults Review using the Significant Incident Learning Process of the Circumstances concerning Kamil Ahmad and Mr X. Mr Ahmad was murdered by Mr X; they were both tenants in the same housing accommodation which was provided by a charity supporting people with mental health problems.

West Sussex Safeguarding Adults Board (2018) Safeguarding Adult Review In respect of Matthew Bates and Gary Lewis – Mr Bates and Mr Lewis were residents of the same care home in West Sussex. Both have profound learning difficulties, cerebral palsy and are non-ambulant. They were admitted to an A&E Department on the same day, both suffering fractures to a femur.

Bristol – Safer Bristol Partnership (2017): Multi-Agency Learning Review Following The Murder of Bijan Ebrahimi, an Iranian man who was murdered after suffering years of harassment and 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.

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.

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.

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.

South Gloucestershire Safeguarding Adults Board (2012) Winterbourne View – abuse by staff at hospital for adults with autism and learning disabilities.

Warwickshire Safeguarding Adults Partnership (2010) The Murder of Gemma Hayter – murder of a woman with learning disabilities.

Cornwall Adult Protection Committee (2007) The Murder of Steven Hoskins – murder of a man with learning disabilities.


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

Inquiry Reports

Gosport Independent Panel Report (2018) – Inquiry report into deaths at Gosport War Memorial Hospital

Department of Health (2013) Winterbourne View Hospital: Department of Health review and response

Mid Staffordshire NHS Foundation Trust Public Inquiry (2013)

More information: