Safeguarding Partners

Please find below the links to the Safeguarding Adults Review (SAR) concerning Violet, commissioned by the Hertfordshire Safeguarding Adults Board (HSAB). This review examines the circumstances surrounding a serious sexual assault in a care setting and highlights significant learning for all partner agencies. Several aspects of the Violet SAR resonate with our own SAR due to be published, particularly around care home safety, the quality of information upon admission, and the challenges of managing residents whose behaviours pose significant risk.

Key learning points include:

• Critical gaps in information sharing between care providers, mental health services, Adult Care Services and the police.
• Use of vague terminology such as “sexualised behaviour,” which obscured risk and hindered safeguarding responses.
• Delays and inconsistencies in the care home’s response, including failure to promptly notify police, family members, or day staff.
• Lack of coordinated multi‑agency planning following the incident.
• Systemic issues around recording safeguarding concerns, risk assessment, and the availability of specialist placements for individuals with dementia who pose sexual risk.

The SAR makes several important recommendations, including:

• Clearer guidance on responding to sexual harm in care settings.
• Consistent recording of safeguarding concerns on both victim and perpetrator files.
• Routine multi‑agency strategy meetings for sexual harm cases.
• Improved information sharing at every transition point.
• Development of specialist provision for residents with cognitive impairment who present sexual risk.
• Co‑produced local guidance to support safer care environments.

This review is essential reading for all teams involved in adult safeguarding, commissioning, care provision, and frontline practice. Please ensure it is shared widely within your service areas and discussed in relevant team meetings, supervision, and training sessions.

SAR Violet Report – https://www.hertfordshire.gov.uk/doc/adult/hsab/hsab-sar-violet-report.pdf

7-Point Briefing – https://www.hertfordshire.gov.uk/doc/adult/hsab/7-point-briefing-violet.pdf