Learning from Experience Database - Serious Case Reviews

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Adult A (Tameside)

Adult A died on the evening of 10th March 2010. He died suddenly as he cleared papers young people had scattered in his garden. His death was found to be from natural causes. The Pathology Report refers to a combination of a heart attack and a small cancerous tumour at the junction of his oesophagus and stomach. Adult A, and his family, experienced taunting, harassment, and damage at the family home during the day and in the evening of his death. The pathologist stated that the stress of the harassment could have exacerbated the medical issues but he could not confirm that was the case. Adult A had some learning disabilities from birth and his speech could not always be understood. He was generally described as having a moderate learning disability, though no formal assessment appeared to be available on agency records. In spite of his disability he was very active, had been in paid or voluntary work for a number of years, and he travelled independently. He had rarely seen a doctor and his underlying health conditions identified after his death were not diagnosed.  Adult A’s mother and brother were also considered as vulnerable adults.  Detailed chronologies of events from January 2007 to March 2010, prepared by a number of agencies as part of this review, indicate that there were over 90 recorded incidents of, burglary, harassment and general anti-social incidents at Adult A’s home; or tormenting, theft and assault against him when he was out in his local community.  During that three year period, 26 named young people, mostly young men, were identified as being involved in these incidents and two thirds of these were identified as having had some contact with the Youth Offending Service. A small number were subject to Acceptable Behaviour Contracts (ABCs), 3 received Anti-Social Behaviour Orders (ASBOs) and at least 1 was given a custodial sentence. Not all their behaviour/offences focused solely on Adult A and his family. There were also other unknown people, including some thought to be as young as 5 years old, whom agency staff and neighbours witnessed harassing Adult A.  This case was reported to the EHRC as an example of disability hate crime.

Professional learning:

  • Information and opportunities to identify hate crime that enable staff and disabled people to raise awareness of the issue.
  • Multi-agency training to address safeguarding issues arising from persistent anti-social behaviourand enable staff to consider how they can work together to manage risk and when to escalate concerns to more senior decision makers.
  • Use of an electronic multi-agency data system to enable the collection, collation, and analysis of data so as to better inform multi agency risk assessment and management.
  • Introduction of an ‘evidential file’ approach where individual incidents are rated low risk but there is a repeating and/or escalating pattern so as to better inform multi agency risk assessment and management.
  • Use of ‘a case finding’ approach to identify other individuals who may be in/at risk of similar circumstances to Adult A, particularly where there are older carers who may have diminishing capacity to protect their disabled son or daughter.
  • Development of a common process and tools to assess and manage community risk, using learning from MAPPA and MARAC processes.
  • Promote learning arising from research about the health inequalities experienced by learning disabled adults and ensure all services make reasonable adjustments to ensure equal access to health services, including preventive health measures.
  • Promote regular health checks for learning disabled adults. Consistent use of Health Action Plans with individuals and family/supporters as appropriate.
  • Where abuse continues to take place alerts should be made by any agency to the Safeguarding Unit even when a member of adult services’ staff is actively involved with a service user.
  • Cases should not be closed to social workers/care coordinators where protection issues continue even when service providers are involved.
  • When abuse is persistent and responsibility for safeguarding is shared by a number of agencies, a lead professional should be identified as having the overall safeguarding responsibility to ensure protection plans are being actioned; regular monitoring is taking place; and where protection is not being achieved concerns are escalated to senior managers in all relevant agencies.
  • Use of events bringing local residents and professionals together to share the learning from serious cases in order to address the intergenerational effects of abusive behaviour.

2011 March Serious case Review regarding A (Tameside)