The purpose of a SAR is to:

• Establish whether there are lessons to be learned, including good practice
• Determine how relevant agencies may have worked differently together, in order to have prevented harm or death, and to prevent similar from happening again.
• Review the effectiveness of procedures
• Identify how the changes required will be brought about
• Improve practice by acting on learning and highlighting good practice, to improve outcomes for adults with care and support needs and their families

What it is not:

• A SAR is not a criminal investigation to determine who is responsible – that is for the police to determine if necessary
• It is not seeking to establish how a person died - that is for the Coroner to investigate
• It is not a disciplinary investigation - that is for each individual agency to deal with if necessary
• The purpose of a SAR is not to hold any individual or organisation to account. They are undertaken solely for the purpose of learning from individual cases, where agencies could have worked better together.