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Introduction
Retrospective “inquiries” are a long-established method of understanding the conditions and particular actions that supported and enabled the abuse and neglect of people with care and support needs. Whilst it is difficult to trace the origins of “the inquiry” as a method of preventing future abuse, several researchers point to the 1969 “Ely Hospital Inquiry Report” as the first large-scale modern inquiry into allegations of widespread abuse at an national health service care setting (Butler and Drakeford, 2003; Walshe, 2002). It is over 50 years since this inquiry, and the practice of inquiries both larger scale and smaller has developed and streamlined over this period (Butler and Drakeford, 2003). In the field of Adult Social Care, The Care Act 2014 (section 44) included a statutory provision for local Safeguarding Adults Boards (SABs) to commission a safeguarding adult review (SAR) to review the experiences of an adult with care and support needs if there is an established concern about how relevant agencies coordinated to safeguard an individual for abuse or neglect (Department of Health, 2014). SARs, therefore, are a multi-agency inquiry following the death or serious harm of an adult with care support needs, when there is some indication that the harm they experienced might have been preventable (Department of Health and Social Care, 2022). The overall aim of a SAR is to establish the learning and development needs that can improve service provision and seek to prevent a similar tragedy occurring again (SCIE, 2015). The expressed purpose of the SAR is not to apportion blame, but to consider the collective working of each service’s safeguarding procedures and how effectively services operate in partnership (Cooper and White, 2017). To date there have been over a thousand SARs published, many of them freely available to view in the online SAR library (SCIE, 2022b). These documents are worthy of further research firstly because they represent an insight into the daily delivery of often highly complex multi-disciplinary support and care interventions for adults at risk of harm, and secondly their knowledge and recommendations form part of the evidence base for effective practice in Adult Safeguarding – a core component of social work practice with adults. This research aims to critically examine the impact of SARs on social work...