Safeguarding Adults Reviews

When there is any failure in safeguarding, the results can be severe and tragic and therefore demand a strong response.

The Care Act 2014 states  that Safeguarding Adults Boards must arrange a Safeguarding Adults Review (SAR) in some circumstances – for instance, if an adult with care and support needs dies as a result of abuse or neglect and there is concern about how one of the members of the Safeguarding Adults Board acted.

The Reviews are about learning lessons for the future. They will make sure Safeguarding Adults Boards get the full picture of what went wrong, so that all organisations involved can improve as a result.

Any relevant person or organisation must provide information to Safeguarding Adults Boards as requested.

Safeguarding Adults Review Policy

Portsmouth SAR subgroup

Portsmouth’s SAR subgroup has been set up to carry out the functions as set out by the Care Act 2014.

The SAR subgroup is made up of representatives of the following partner agencies:

  • NHS Portsmouth Clinical Commissioning Group
  • Portsmouth City Council (chair)
  • Hampshire Constabulary
  • Portsmouth Hospitals University NHS Trust
  • Solent NHS Trust
  • South Central Ambulance Service NHS Foundation Trust
  • Hampshire Care Association

Publication of Portsmouth Reviews

Thematic review following the deaths of Mr G, Mr H, Mr I and Mr J (2022)

Thematic Review report

Thematic Review learning summary

The chair of Portsmouth Safeguarding Adults Board, David Goosey, said:

“Today we have published an independent review into the deaths of four men who sadly died in Portsmouth in 2020. All four were homeless at the time of their deaths.

“None of the deaths were linked to abuse or neglect, but we identified that there had been a number of similar deaths at this time and chose to carry out a review to see what could be learned and to identify improvements in the way services in the city support homeless people.

“These four cases were chosen purely because they seemed representative.

“The review has highlighted the unprecedented challenges experienced by individuals and services at the height of the Covid-19 pandemic in 2020. It also has a number of recommendations. I am pleased to note that a great deal of work has already been done to improve outcomes for homeless people.

“These include:

  • the introduction of a healthcare team based in Portsmouth City Council’s homeless day service
  • strengthened links between housing and social care services, including a specialist council social worker based in the homeless service run by the Society of St James
  • homeless liaison officers from Two Saints based at Queen Alexandra Hospital, who support patients and visitors with housing issues
  • new housing and substance-misuse services. For instance, the council’s services for rough sleepers have been re-designed and now include three buildings, converted from student accommodation, which offer intensive, medium, and lower levels of support according to individual needs. Services work with people to help them move along a pathway into settled accommodation.

“The board and our partner agencies are also developing an action plan which will ensure that relevant learning is taken into account in the future provision of services for homeless people. We are also working on new guidance for staff and will be offering further training opportunities.

“On behalf of the Portsmouth Safeguarding Adults Board, I would like to express my sincere condolences to each of the families involved.”

Safeguarding Adults Reviews Mrs E and Mr F (2022)

Mrs E Executive Summary report

Mr F Executive Summary report

Mrs E and Mr F learning summary

The chair of Portsmouth Safeguarding Adults Board, David Goosey, said:

“The Portsmouth Safeguarding Adults Board has today published reviews into the circumstances of the deaths of two vulnerable older people, ‘Mrs E’ and ‘Mr F’.

“Although the deaths were unrelated, we have taken the decision to publish these reviews at the same time as they raise common issues for professionals working in health and social care in the city. These include ensuring that partners improve how they work together to identify risks of harm and coordinate their safeguarding responses to vulnerable people, and that family carers are supported and sometimes challenged effectively.

As a result of the findings of these independent reviews, we have developed a comprehensive action plan and the Safeguarding Adults Board will now be working closely with all partner agencies to share and embed the learning and ensure that improvements are delivered in the areas identified in the recommendations.

“On behalf of the Portsmouth Safeguarding Adults Board, I would like to offer our sincere condolences to the families of Mrs E and Mr F.”

For any enquiries, please email

Safeguarding Adults Review Pamela Ratsey (2022)

Pamela Ratsey final report

Pamela Ratsey learning summary

The chair of Portsmouth Safeguarding Adults Board, David Goosey, said:

“This review was commissioned following the tragic death of Pamela Ratsey after neglect at a residential care home in Portsmouth.

“It concludes that health and care services did not work together as effectively as they should have done to address Pamela’s increasingly complex care needs and keep her safe from neglect.

“The agencies involved have since reviewed their services and many improvements have already been made. An action plan is being organised to ensure key lessons are learned with the aim of preventing similar tragedies in future.

“On behalf of the Portsmouth Safeguarding Adults Board, I would like to thank the family of Pamela for their active contributions to the review process and offer them the Board’s deepest sympathy.”

For any enquiries, please email

Safeguarding Adults Review YL (2021)

YL final report

YL learning summary

The chair of Portsmouth Safeguarding Adults Board, David Goosey, said:

“This review was commissioned following the tragic death of YL, a daughter, granddaughter and a mother to a young child.

“It concludes that, although the death was not linked to abuse or neglect, there are lessons to be learned, including how services in the city can work together more effectively to support adults with complex mental health conditions and their families.

“Many improvements have already been made and an action plan is being put in place to address other lessons identified.

“We offer our deepest sympathies to the family of YL and others who knew her.”

For any enquiries, please email

Safeguarding Adults Review Mr D (2019)

Mr D Executive Summary

The report published here – Safeguarding Adults Review of Mr D – has been published alongside a similar report from Portsmouth Safeguarding Children Board due to the prevalence of a number of themes throughout both reports.

You can find a copy of the Learning Review – Child G on the Portsmouth Safeguarding Children Board website.

Mr D / Child G Case Review Briefing Note

Joint statement from the chairs of the Portsmouth Safeguarding Adults Board and the Portsmouth Safeguarding Children Board

Safeguarding Adults Review Mrs B

Mrs B Final Report

Safeguarding Adults Review Mr A

Mr A Final Report


Case Learning Summaries

‘Ms A’ (2020)


SAR referrals

SAR referral form

One minute guide to SAR referrals


Referrals to the Fire Safety Development Group (FSDG)

The FSDG reviews fire deaths and near miss cases in order to learn from them and reduce the risk of these incidents. Cases that meet the following criteria should be considered for a referral to the Fire Safety Development Group.

  • Fatality involving a fire
  • Fire resulting in life-threatening, life changing or serious injuries
  • Fire resulting in near miss, when an individual has / suspected needs of care of support
  • Death, serious injury or near miss (any type not just fire related) involving an individual where high fire risks are identified and may have contributed.

FSDG referral form