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Safeguarding Adults Reviews in adult protection: Guidance and development


To explore the use of Serious Case Reviews (SCRs), since April 2015 renamed Safeguarding Adults Reviews (SARs), in adult services and to make recommendations for policy makers and practitioners and other stakeholders.


2007 – ongoing

Research team

Jill Manthorpe and Stephen Martineau (SCWRU)


Department of Health, Policy Research Programme


Collection of SARs is ongoing. Since there is no central register the approach is investigative: we conduct intermittent internet searches and make enquiry of our extensive contacts in the field. This builds on previous searches undertaken in 2006-2007 and 2012. We conduct thematic analysis by status of the adult at risk, location, or practice activity.


At end 2016, we have collected 135 SCRs/SARs. We continue to analyse them according to ‘type’ of incidents or service user involved. We explored those related to pressure ulcers in 2016. Our analysis has revealed that the SCRs are highly variable where the focus is on an ‘institution’ and often hard to interpret for readers outside the local context. The sources of evidence are not consistently reported and follow-up plans not uniformly presented.


Our articles on SCRs/SARs related to care homes and on dementia care were published in the British Journal of Social Work in 2016. Analysis was also undertaken of pressure ulcer care featuring in SCRs and an article accepted for publication on the Care Act changes.


A summary of our work on SCRs was presented to the DH Safeguarding Adults Board. The findings were used in training for local safeguarding practitioners and commissioners and conveyed to those working on SCRs in children’s services in training events organised by government and voluntary sector bodies.

The original report from this study informed the No Secrets review in 2009. The Unit has been consulted by local Adult Safeguarding Boards about this work and has provided detailed advice.

We have presented findings at local Adult Safeguarding Boards and national authorities in England, Northern Ireland and Ireland of our findings and discussed their relevance to their systems and procedures. Our articles are used in professional training programmes to inform practice across the country.


Martineau, S. J., Cornes, M., Manthorpe, J., Ornelas, B., & Fuller, J. (2019) Safeguarding, homelessness and rough sleeping: An analysis of Safeguarding Adults Reviews. London: NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London.

Manthorpe, J. & Martineau, S., (2009), 'Serious Case Reviews in Adult Safeguarding', London: Social Care Workforce Research Unit, King's College London.

See also

Not part of this project but see also: Emmer De Albuquerque Green, C., Manthorpe, J., & Martineau, S. (2021) A matter of life or death: a rapid review assessment of London’s safeguarding adults reviews to inform the future of mental health adult social care under a new Mental Health Act. NIHR Applied Research Collaboration South London; NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London. 


Martineau, S., & Manthorpe, J. (2020) 'Safeguarding Adults Reviews and homelessness: making the connections', Journal of Adult Protection.

Manthorpe, J. & Martineau, S. (2016) 'Engaging with the New System of Safeguarding Adults Reviews Concerning Care Homes for Older People', British Journal of Social Work, 10.1093/bjsw/bcw102

Manthorpe, J. & Martineau, S. (2014, online) 'Serious Case Reviews into dementia care: an analysis of context and content', British Journal of Social Work. Open Access

Manthorpe, J. & Martineau, S. (2013, online) 'What can and cannot be learned from Serious Case Reviews of the care and treatment of adults with Learning Disabilities in England? Messages for social workers', British Journal of Social Work.

Manthorpe, J. & Martineau, S. (2012) ' "In our experience": Chairing and commissioning Serious Case Reviews in adult safeguarding in England', Journal of Social Work, 12(1): 84-89.

Manthorpe, J. & Martineau, S. (2011) 'Serious case reviews in adult safeguarding in England: An analysis of a sample of reports', British Journal of Social Work, 41(2): 224-241.

Professional press

Manthorpe, J. & Martineau, S. (2014) 'Research review - Lessons for practice under the Mental Capacity Act from Serious Case Reviews', Community Care Inform Adults, 8 July.

Manthorpe, J. (2013) 'The state we're in [guest editorial]', Journal of Care Services Management, 6(4): 1-3.

Manthorpe, J. (2012) 'Latest research findings (Serious Case Reviews)', Community Care, 21 November.


Manthorpe, J. (2013) 'Elder abuse', in Dening, T. and Thomas, A. (eds), Oxford Textbook of Old Age Psychiatry (Second edition), Oxford: Oxford University Press, pp. 779-783.

Manthorpe, J. & Martineau, S. (2011) 'Inquiries and Serious Case Reviews: Listening and learning', in Scragg, T. and Mantell, A. (eds), Safeguarding Adults in Social Work, pp. 180-189, Exeter: Learning Matters Ltd.


Manthorpe, J. (2015) 'Safeguarding Adults Reviews', Milton Keynes Council, Milton Keynes, 24 July.

Manthorpe, J. (2015) 'Defining the perpetrator', Adult safeguarding event, Milton Keynes, 25 June.

Manthorpe, J. (2015) 'The Care Act 2014: a wise and worried workforce', National Care Forum Annual Conference, Reading, 19 May.

Manthorpe, J. (2015) 'Learning from Serious Case Reviews', Errors of Judgement: learning from Serious Case Reviews in adult social care, Ulster University, 4 March.

Manthorpe, J. (2015) 'Safeguarding people with dementia: are there lessons from Serious Case Reviews?', Working with people with dementia and their carers, London, 24 February.

Manthorpe, J. & Martineau, S. (2014) 'Serious Case Reviews: the potential for detailed analysis of care failings', British Society of Gerontology Annual Conference 2014, Southampton, 2 September.

Manthorpe, J. (2014) 'Safeguarding and adult Serious Case Reviews', Luton Borough Council Adult Social Care Conference, Luton, 27 June.

Manthorpe, J. (2014) 'Action on learning from Serious Case Reviews: children and adults', Priory Group Multi-Agency Safeguarding Conference, Mortimer, Berkshire, 12 June.

Manthorpe, J. (2014) 'Longing to learn: Serious Case Reviews and Safeguarding Adult Reviews', Social Work Education Network, 19 March.

Manthorpe, J. (2014) 'Information and adult safeguarding: challenges and dilemmas', Eastern Locality Safeguarding Adults Partnership Spring Seminar, Great Yarmouth, 28 February.

Manthorpe, J. (2013) 'Learning from Serious Case Reviews', London Borough of Richmond, 10 December.

Manthorpe, J. (2013) 'Inquiries and reviews', Essex Safeguarding Adults Board Conference, Chelmsford, 12 November.

Manthorpe, J. (2013) 'Adult safeguarding, past and future', London Borough of Bromley, 5 November.

Manthorpe, J. (2013) 'The implications of the Francis Report for adult safeguarding', University of East Anglia, Norwich, 25 October.

Manthorpe, J. (2013) 'The changing face of Serious Case Reviews', Sequeli Training Event for Cumbria County Council, Penrith, 14 October.

Manthorpe, J. (2013) 'Learning the lessons from Serious Case Reviews [also the event co-organiser]', The Royal Society of Medicine, London, 26 September.

Manthorpe, J. (2013) 'Publishing and communications in Serious Case Reviews', Sequeli/NSPCC Training programme for the Department of Education, Leeds, 3 July.

Manthorpe, J. (2013) 'What can safeguarding learn from personalisation?', Health and Care Conference, London, 12 June.

Manthorpe, J. (2013) 'Care homes and safeguarding', East Renfrewshire Annual Safeguarding Conference, Giffnock, 7 June.

Manthorpe, J. (2013) 'The safeguarding future', West London NHS Mental Health Trust, London, 16 May.

Manthorpe, J. (2013) 'Publishing and communications', Sequeli/NSPCC for the Department for Education, Training & Support Programme on Children’s Serious Case Reviews, London, 15 May.

Manthorpe, J. (2013) 'Learning the lessons - Developing responsible approaches and early interventions in every local area', Public Policy Exchange, London, 8 May.

Manthorpe, J. (2013) 'Adult safeguarding and dementia care', Dementia Conference, London, 2 May.

Manthorpe, J. (2013) 'Safeguarding', London, 30 April.

Manthorpe, J. (2013) 'Supporting staff in safeguarding', NW London Training Day in Geriatric Medicine, Imperial College, St Mary's Hospital, London, 26 March.

Manthorpe, J. (2013) 'Acting on learning from Serious Case Reviews', National Safeguarding Adults Conference, London, 24 February.

Manthorpe, J. (2013) 'Social care law', Royal Borough of Kingston, 19 February.

Manthorpe, J. (2013) 'Safeguarding adults: policy and practice', National Safeguarding Conference of the Church of England and the Methodist Church, York, 23 January.

Manthorpe, J. (2013) 'Adult safeguarding policy and practice', Making Connections: Addressing the complexities of IPV, The Centre for Children, Young People and Families, Fourth Seminar in the series: Tackling Interpersonal Violence - Finding out what works, Sunderland, 18 January.

Manthorpe, J. (2012) 'Are Serious Case Reviews the best way of learning - what are the alternatives?', Annual Conference of Action on Elder Abuse, London, 30 March.

Manthorpe, J. (2010) 'Taking it seriously...working on serious case reviews', New Types of Working in Health and Social Care: Second International Research Conference, London, 31 January.

Manthorpe, J. (2010) 'Serious Case Reviews in adult safeguarding', Adult Safeguarding Conference, London, 26 January.

Manthorpe, J. (2009) 'Improving safeguarding practice: learning from Serious Case Reviews', Safeguarding Vulnerable Adults: Implementing 'No Secrets', Manchester, 8 December.


Manthorpe, J. (2015) 'Self-neglect and safeguarding: indicators for good practice', The Social Care Elf, 4 June.

Manthorpe, J. (2015) 'What do serious case reviews say about self-neglect?', The Social Care Elf, 30 April.

Norrie, C. & Graham, K. (2013) 'Nearly there? The Care Bill and adult safeguarding', Social Care Workforce:, 5 November.

Norrie, C. (2013) 'Avoiding more Winterbourne Views: What can we learn from history?', Social Care Workforce:, 15 July.


3 December 2010 Community Care
The British Journal of Social Work article by Manthorpe & Martineau examining a sample of Serious Case Reviews is discussed by Ann McDonald, head of the school of social work at University of East Anglia.

Related event

7 March 2012 Research into reviews and investigations: an in-depth look
Includes Professor Manthorpe speaking on serious case reviews in adult safeguarding.
This is one of a series of sequeli workshops. See Events 2012

Related work

Manthorpe, J., (2008), 'No Secrets: Messages from Research', Manchester City Council, 15 December, Manchester.

Project status: Ongoing

Principal Investigator