Learning from Experience Database - Serious Case Reviews

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Wyton Abbey (East Riding)

This serious case review was undertaken to examine care offered between May 2011 and November 2012 to three people, two of whom died. The third person continued to live at Wyton Abbey. The circumstances were thought to be significant enough for a serious case review because of the medical condition of the residents and the range and depth of concerns about the safety of the home identified by both CQC and East Riding’s contracting unit and safeguarding team. The Coroner’s report on one of the residents concluded that he might not have died if he had received more timely medical help. From July to November 2012 placements were suspended at Wyton Abbey Care Home, owned by Prime Life.

There were concerns that despite several interventions over a seven-month period, there was no evidence of improvement in the care provided. The Coroner’s narrative verdict concerning one of the people who died said that earlier intervention might have postponed the time of his death.  During this period, a number of statutory partners were involved with Wyton Abbey over the period in question.

Professional learning:

  • The 23 recommendations contained in the SCR report fall into two categories:
  • The systems and processes needed to ensure the effective management of care in residential/nursing homes (including effective clinical management, care planning effective systems to monitor the delivery of care on a day to day basis, clear documentation and recording) and
  • Contracts and commissioning activity should support the safeguarding process for example, by implementing timely contract compliance and defaults measures and sanctions. This case also raised the question of whether there is sufficient focus within contracts and commissioning teams on supporting care providers re quality improvement (and continuous improvement) as a means of preventing the escalation of poor quality care into the safeguarding arena.  Quality monitoring must have an outcomes rather than target focus.

2013 Serious case Review regarding Wyton Abbey Care Home East Riding

Mid Staffordshire NHS Foundation Trust

The independent Inquiry highlighted a whole systems failure with on the Trust with poor standards nursing care at the centre of this.  Issues identified included failure of clinical leadership and professionalism; poor communication with patients and relatives; poor monitoring and recording of food and fluid intake; failure to respond to symptoms and requests for help e.g. patients left to soil themselves in bed, increasing risks of infection and pressure sores and call bells not answered.  The root causes of these failings and lessons were identified as follows:

  • Poor clinical practice, medication, infection control;
  • Poor culture and failure by professionals to speak out.
  • Poor care to go unchallenged and those who did speak up found themselves side lined, bullied, threatened.
  • Skills deficit regarding the care of people with dementia
  • Skills deficit re care of people with a learning disability
  • Absence of Person Centred Care
  • Absence of Dignity in Care
  • Poor communication
  • Poor recording
  • Nurses not taking responsibility for care delivered
  • Poor leadership and lack of professionalism
  • Nurses not taking a proactive approach
  • Lack of CPD and clinical updating

In March 2013, the Department of Health published First and Foremost, in which its commitment to providing compassionate, high quality patient care that protects the rights and dignity of patients. First and Foremost outlines a five point plan to remedy the deep rooted and systemic failings uncovered by the Francis Inquiry which focuses on:

  • Preventing problems
  • Detecting problems quickly
  • Taking action promptly
  • Ensuring robust accountability
  • Ensuring staff are trained and motivated

2013 February Public Inquiry into Mid Staffordshire NHS Foundation Trust Executive summary

Torbay NHS Trust

This Serious Case Review was commissioned to consider historical safeguarding adults concerns dating back to 2007 regarding the possible abuse of residents in a nursing home.  The Review looked at the evidence for alleged poor or abusive practice. Records were found to be incomplete, with inconsistencies between records held by different agencies of safeguarding activity, which made it difficult to gain a full picture of the concerns, action taken and outcomes. The concerns led to 21 safeguarding strategy meetings and the majority of these were followed by one or more case conferences. On four occasions the concerns raised were substantiated but further action was taken in only two cases. It was not possible to be certain about whether any abuse was suffered by residents of the nursing home during the review period, or about the standard of care or management of the home at that time. Investigation of these matters at the time was inconclusive and subsequent enquiries have been similarly inconclusive. However, during the review period there were persistent and significant concerns that residents may have been subject to abuse, evidenced by the number of complaints and safeguarding alerts made by residents, relatives, staff and visiting professionals and the associated safeguarding activity. A Whole Home Investigation was held due to the large number of safeguarding concerns to consider the risks to all the residents in the home. This Whole Home Investigation lasted for more than two years and failed to reach a conclusion.

Professional learning:

Decisions to undertake a Whole Home Investigation should be taken at a senior level with due consideration and that the Investigation has clear leadership, management oversight and is adequately resourced so that the work can be carried out within a reasonable timescale.

Safeguarding adults policies and procedures should be reviewed to ensure that the relationships between the commissioning, contract monitoring and safeguarding are clearly specified and that safeguarding matters must have primacy in decisions about commissioning and contracting.

Contracts, commissioning and regulatory staff should have a means of monitoring the take-up and delivery and impact of training modules for staff at all levels in the NHS and the independent sector.

The need to review the arrangements for the provision of health care to residential and nursing homes to make the most effective use of a limited resource and ensure as far as possible continuity of healthcare to residents.

Fully integrated healthcare should be provided to all residential and nursing homes with close clinical oversight and support to home managers. Opportunities should be explored for linking GP practices to Care Homes. Care, nursing and treatment plans must be fully aligned.

GPs should put their medical notes into the Care Home notes as well as their own surgery notes.

The review highlighted CQC’s failings in the follow up of concerns received as a result of operational difficulties within CQC and the adoption of new inspection and review methodologies.

2013 September SCR regarding Torbay NHS Trust

DD (Slough)

DD first became known to Adult Social Care in December 2007 when, following an admission to hospital, she was referred by a GP for social care assessment. This assessment concluded DD was managing relatively independently with low level input from Age Concern; family members and assistance with housework funded and arranged privately. There were further concerns in late 2008 and in the first half of 2009 relating to DD’s ability to manage independently and references in particular to her memory and a level of confusion. There were concerns about safety in relation to DD’s use of the gas cooker and an incident where she had locked herself out. She was in receipt of a meals service. Following a fall in November 2009 DD was again admitted to hospital and following discharge a package of care was arranged including three calls daily to assist with daily living tasks. DD continued to receive care from the care agency from this point until her death in May 2012. DD was referred to the Community Mental Health Team for Older People in January 2010. The GP was also involved during this time, including responding to calls from family and from carers from the care agency. Following her discharge from hospital in May 2012, DD died in circumstances which gave rise to significant concerns about the way in which local professionals and services had worked together in this situation.

Professional learning:

  • The importance of a robust multiagency approach to achieve a holistic overview of needs and risks.
  • The importance of clear recording with the rationale for actions and decisions taken clearly documented.
  • The importance of statutory agencies both seeking out information from front line carers to inform assessment, monitoring and review processes and sharing information with them.
  • The lack of a person centred approach can impact significantly on the quality of intervention.
  • The importance of offering a carer assessment.
  • The importance of robust risk assessment and risk management and the need to coordinate information and decision making around the known risks.
  • The importance of engaging the service and family members in the risk management process and plan.
  • Recognition that robust recording is an essential part of practice especially in circumstances of risk and the value of standard recording formats in key areas such as risk; safeguarding adults; mental capacity assessments.
  • Recognition that responses to self neglect/refusal of support have to be considered in the context of the person’s mental capacity.
  • Failure to carry out a timely assessment to ascertain a diagnosis of dementia contributed to an absence of personalised care, any clear strategy to manage risks and plans and contingencies to optimise care.

2012 May SCR regarding DD (Slough)

A2 (Birmingham)

A2 died in April 2012, in an inpatient palliative care unit for people in the final stages of illness. The cause of death was recorded as dementia, peripheral arterial disease and type 2 diabetes. Since an admission to hospital on 1st November 2011, an end of life pathway had been pursued, keeping A2 comfortable. He was cared for in a nursing home prior to the admission to the palliative care unit and was in receipt of continuing health care funding. A2 also suffered from mental ill health with a diagnosis of paraphrenia and it was at times unclear as to whether he understood the implications of his failure to engage with either health or social care professionals. In November 2011 he was also diagnosed with dementia. A2 was reluctant to engage with professionals despite considerable health needs as well as care needs and safeguarding issues which he alternately acknowledged and denied. His frequent failure to turn up for appointments and declining of support meant that agencies were challenged in their attempts to support him.

Professional Learning:

  • The need for professional to understand the basis upon which service users may decline to work with professionals.
  • The importance of exploring service user’s ability to make judgements about declining health and social care support.
  • The importance of timely mental capacity assessment and use of Independent Mental Capacity Advocates to support best interest decision making.
  • Consideration of a range of legal alternatives associated with the risks inherent in A2’s situation. Professionals should be aware of and/or have easy access to advice on those alternatives.
  • The importance of a holistic assessment informing discussion of the relative role of the two pieces of associated legislation.

2012 September SCR regarding A2 (Birmingham)

Ward 17 Luton and Dunstable Hospital

This independent review considers the circumstances surrounding the alleged sexual abuse/inappropriate behaviour toward 15 men on ward 17 of the Luton and Dunstable Hospital, (L & D Hospital), between October 2008 and January 2011. The alleged abuse took place on ward 17 which was, and remains at the time of writing, the adult stroke rehabilitation ward. It is therefore not difficult to conclude that all the victims could be defined as vulnerable adults.

2012 September Joint Safeguarding Case Review re Ward 17 Luton and Dunstable Hospital

LW (Dorset)

LW was 26 year old woman who had a long and extensive psychiatric history. She had a diagnosis of Borderline Personality Disorder (BPD) although this diagnosis was under review towards the end of her life. She was admitted informally to psychiatric hospital during the night, saying she was low in mood and planning to kill herself. She was detained under section 5 (2) of the Mental Health Act and this was subsequently converted to a section 2 several days later. In the context of LW appearing to be more settled and relaxed, she was allowed two towels and went to take a bath. She was found collapsed in the bathroom twenty five minutes later, with a ligature around her neck and an injury to her head. LW was taken to Dorset County Hospital but never regained consciousness and she died on 28 February 2011.

Professional learning:

  • Improvements needed in the understanding of the wider remit and value of safeguarding adults policies and procedures, across all the agencies.
  • Improvements information sharing and co-ordination of care and support across all agencies including emergency and 24 hours services for the small number of people identified with multiple and highly complex needs, to ensure all relevant agencies can work together effectively and overcome the general and specific difficulties service boundaries create.

2012 SCR regarding LW (Dorset)

Mrs B (Blackpool)

Mrs B relocated to Blackpool in January 2010 to be closer to her granddaughter after being discharged from hospital to a care home following a fall at home. Mrs B had lost the sight in her left eye, had history of frequent falls and was known to have vascular dementia and a range of other health issues. Between April and September 2010, Mrs B’s granddaughter twice contacted BC to raise concerns about the standard of care her grandmother was receiving and requesting information about how to arrange an alternative placement. These concerns included incidents of apparent poor care, poor staffing levels and a degree of restraint being used. Following the second alert, an unannounced joint visit to the home took place some time after. Some of the family’s concerns had been addressed and the family are reported as feeling that staff were being more attentive to Mrs B. An alternative placement was discussed. The family agreed for Mrs B to remain at the home and the owner was advised to apply for a Deprivation of Liberty Authorisation with regards to Mrs B’s best interests.  A week after the visit, Mrs B was taken to hospital in an ambulance following a fall. She was seen in A&E and given treatment for a cut to her head. Mrs B was then transferred back to the care home.  A safeguarding referral was made regarding injuries Mrs B had sustained possibly from falls. The allegations could not be substantiated and it was not possible to establish what happened to Mrs B who died in hospital on 6 November 2010.

Professional learning:

  • There is limited evidence to show that Mrs B’s needs were adequately met and there were at least two occasions when safeguarding procedures should have been triggered. A more proactive and timely response to Mrs B’s care needs would not have had a positive impact on the quality of her life.
  • Assumptions were made that others were doing what was necessary and/or making a referral to another agency and these actions were not verified. It was the view of social workers, nurses (including the owner of nursing home) that Mrs B was suffering from dementia yet no one arranged for her assessment by an appropriate specialist.
  • Throughout the time Mrs B was a resident at BNH her family had reservations about whether she was receiving an appropriate standard of care to meet her needs. Staff should explore with relatives who express concerns their reasons for these and these to be recorded in the client record.
  • Families should had the opportunity to attend safeguarding meetings (or part) to provide their perspective and contribute valuable information about the care provided to their relative.

2012 April Serious Case Review regarding Mrs B (Blackpool)

Mrs B (Central Bedfordshire)

Mrs B was admitted to Bedford Hospital on 10 May 2012, with a suspected stroke. Examinations revealed that she was suffering from advanced stage cancer and given a poor prognosis, it was decided that she would be provided with palliative care. It was arranged that this would be provided in a local nursing home, where her husband had been admitted when Mrs B was taken into hospital. She had been his carer, as he suffered from dementia. She was admitted to the same care home on 1 June 2011 and died there on 4 June 2011. The family and some professionals, raised concerns about the care that Mrs B had received and a safeguarding investigation was commenced on 8 June 2011 the outcome of which was ‘not determined/inconclusive’. A recommendation was made to the Safeguarding Adults Board to consider commissioning a Serious Case Review to consider whether she was provided with appropriate care at the end of her life.

Professional learning:

  • Commissioners should ascertain how appropriate support is assured when non-specialist or inexperienced facilities are used to provide the more specialist aspects of end of life palliative care.
  • Multi-disciplinary and proactively framed palliative care plans, including pain management plans, should embedded into local practice of health and social care providers and that families are appropriately engaged in the process.
  • Mechanisms should be developed to facilitate early communication with GPs, for newly admitted care home residents, who need to be newly registered with a GP practice.
  • Patients being discharged from the hospital to care homes, should be given their own copy of the doctor’s transfer letter.
  • NHS to have mechanisms to review the consistency of the content of the nurse led transfer summaries, to ensure that any forward care and medication requirements are clearly stated, where appropriate.
  • Clear standards should be put in place regarding the nature and content of documentation that should accompany medication sent from hospitals to care homes.
  • Thresholds for involving palliative services and the Macmillan service should be agreed and communicated to relevant partners.
  • Mechanisms should be in place to ensure local ‘end of life’ strategy and practice is compliant with the NICE quality standards issued in November 2011.

2012 April Serious Case Review regarding Mrs B (Central Bedfordshire)

MM (Essex)

MM was an 89 year old lady living in her own home with a good network of support from her local church. She was estranged from her daughter. MM also had an adult son with cerebral palsy and mental health issues living independently. She had a strong dislike of anyone associated with Social Services since she believed they were responsible for ‘removing’ her son from her home when he moved to live independently in 2004. As a result of concerns about her husband’s care in hospital prior to his death in 2006 MM was also resistant to hospital admission. MM was often described as difficult or cantankerous by those who had involvement with her.  She had deteriorating health between January 2009 and May 2012. However, consistency refused care. Following significant deterioration in her condition and mental capacity, MM was admitted to hospital where staff recorded her in a foetal position covered from neck to toe in faeces and urine. MM’s hair was also noted as matted. Noted as having ground in faeces, reported as soaked but still staining the skin. MM continued to deteriorate and died on 6th May 2012.

Professional learning:

  • The need for clear guidance on managing self-neglect in the context of mental capacity and best interests.
  • Better understanding of the role of the Mental Capacity Act by agencies, particularly GPs. Specifically with this case there had been confusion between the applicability of Mental Capacity Act and the Mental Health Act.

2012 Serious Case Review regarding MM (Essex)

Mr and Mrs R (Northamptonshire)

This serious case review was initiated following the death of Mr and Mrs R. The coroner has determined that both died of natural causes. Both had serious on-going poor health and both had been referred and were receiving support for health and social agencies. The coroner was satisfied in both cases that an inquest was not needed. This case falls outside the usual range of situations that would normally prompt a serious case review. Nevertheless, the case prompted much media attention, with speculation that the agencies could have acted differently, and the implication that they could have prevented both deaths.  The SCR confirmed that there was no evidence of an abusive situation and the circumstances did not meet the criteria to be consideredas one of ‘safeguarding vulnerable adults’. However, The couple’s vulnerability increased as their health deteriorated and there were some points in the situation where that increasing vulnerability might have been more clearly identified. This may, in turn, have led to more robust efforts on the part of the agencies to persuade Mr and Mrs R to accept interim or longer term support. However, this did not emerge as a situation that would have met the criteria for intervention at the level of ‘safeguarding vulnerable adults’.

2010 June Serious Case Review regarding Mr and Mrs R (Northamptonshire)

Mr A (Southampton)

Mr A was a 49 year old man who had a mild to moderate learning disability as well as epilepsy and scoliosis. He had lived in supported accommodation since his early twenties and in December 2006 he moved to supported living provided by Wessex Regional Care Ltd a service which provided tenancies domiciliary support to people with learning disabilities. In the last three months of his life Mr A became physically ill and suffered from recurring stomach complaints. He was also adversely affected by the level of disturbance within ‘the flats’ caused by both the nature and mix of the residents. In the last week of his life Mr A had continued stomach problems which were not adequately dealt with. On Monday 20 December Mr A died from natural causes, defined by the coroner as a combination of dehydration, colitis and epilepsy. The SCR was established to investigate how death could have occurred in a supporting living establishment with staff available 24 hours a day. It concluded that Mr A’s death was preventable. The cause of Mr A’s death was systemic. A group of contributory factors combined to create a situation where a vulnerable adult was allowed to die in circumstances where he was living in supported accommodation. The Coroner in his narrative report came to the conclusion that Mr A’s death had been “preventable and unnecessary” and “that the systems in place to deal with Mr A’s health generally were inadequate and insufficiently robust”.

Professional learning:

  • If safeguarding concerns involve more than one vulnerable adult, meetings must give equal attention to each and assess respective needs/risks and the inter-relationship of these.
  • Monitoring of contracts should include initial monitoring of the level of support needed, confirmation that the care plan reflects identified needs; ongoing review of the level of support offered; quarterly checking of the records showing how that support has been provided and outcomes; spot checks of the property.
  • Providers should record a summary of their assessment, advice or the outcome of their visit in the service user’s ongoing record.
  • Visiting professionals who have concerns about the standard of care and/or the general state of the environment should raise concerns with the senior member of staff on duty; request details of the provider organisation and the commissioning organisation; be aware of their professional code of practice to highlight any sub-standard care.
  • Clear policies and practice guidance disengagement/refusal of support should be available. A protocol and thresholds should be agreed locally as to when incidents of refusal are escalated internally and out to care management teams.
  • Commissioners should assure themselves that provider staff have the necessary knowledge and competence re MCA practice.
  • Protocols must be in place in provider services about informing relatives of a family member’s illness so that they can be involved in decision-making around the service user’s care.
  • Police and anti-social behaviour teams should monitor frequent incidents/call
  • outs to the same address (particularly where it is a multiple occupancy).
  • Thresholds should be in place as to when to make a safeguarding referral.

2012 July Serious Case Review regarding Mr A (Southampton)

JT (Dorset)

Mrs JT died on 29 May 2012 as a result of a stroke. She had, in January 2012, been admitted to a care home. This was an emergency measure because her husband, who was her main carer, had suffered a stroke and was admitted to hospital. In March 2012 JT transferred to a nursing home, where she died.  JT’s general condition and health on admission to the care home in January 2012 gave rise to significant concerns as a result of which a safeguarding alert was raised and an investigation ensued. This subsequently gave rise to questions about the way in which local professionals and services had worked together in this situation. JT was an adult at risk known to a range of health and social care agencies. She had a range of health related conditions which rendered her increasingly dependent and isolated. JT was, for her own reasons, at times reluctant to accept care and treatment offered by professionals. This should have been explored with her by staff and professionals. This reluctance, combined with the increase in health and care needs was challenging to the effective management of risk. The situation demanded basic good practice, a high level of continuity and communication across agencies as well as an ability to keep track of a situation, which continued over two decades, in order to ensure that needs and risks were adequately addressed. A number of failings combined in this situation leading to agencies and professionals failing to recognise, acknowledge and address the serious level of deterioration in JT’s condition

Professional learning:

  • The need for a clear framework for the identification, assessment and management of risk across agencies including a focus on working with those who are reluctant to engage with services and treatment.
  • Improvements in monitoring practice in relation to the Mental Capacity Act.
  • Implementation of best practice in working with stroke illness.
  • Improved practice in working alongside carers and in carrying out carers’ assessments
  • Better understanding of the relationship between pressure ulcer care and safeguarding adults.
  • Ensuring robust practice in relation to Do Not Attempt Cardio Pulmonary Resuscitation (DNAR).

2012 May Serious Case Review regarding JT (Dorset)

WL (Northamptonshire)

WL died in Hospital on the 5 August 2009. He had complex needs, health and social care and was also registered blind. He had a diagnosis of Down’s syndrome. He had lived with his parents until his admission into care in 1997 where he stayed until June 2009. The records from a number of key agencies involved with this Serious Case Review (SCR) indicate WL’s health and social care needs started to change noticeably from the beginning of 2008. His increasing frailty can be seen to continue in the multi-agency recordings and in the latter part of 2008 a move for WL to a care service with nursing capability was being discussed; but not implemented prior to his admission to Northampton General Hospital NHS Trust (NGH) by Ambulance on the 1st June 2009. His presenting physical condition was of marked concern to WL’s Father. He was admitted with sores, dehydration and infections. He subsequently died in Hospital on the 5th August 2009.

Professional learning:

  • Implementation of a defined learning disability care pathway for A&E and general wards in hospitals to enable reasonable adjustments to be made.
  • Implementation of communication passports providing essential information about the patient in order to ensure staff are aware of the patient needs and to inform care and treatment plans.
  • Implementation of a carers’ policy to support both formal and informal carers.
  • Ensuring that patients with learning disabilities and/or their carers are informed and participate in patient satisfaction survey.
  • Development of resource/tools, with reasonable adjustments so that patient’s experiences within hospital are recorded.
  • Guidelines on referrals to safeguarding and to the coroner should include specific reference to neglect.
  • Escalation arrangements in care services and competencies in this regard which include specific reference to capacity and consent issues (linked to the Mental Health Act and DOLS).

2012 November Serious Case Review regarding WL (Northamptonshire)

Mr H (Northumberland)

This SCR examines the circumstances leading up to the death of Mr H. He lived in sheltered accommodation and whilst he had some long term physical conditions, Mr H was able live very independently until the last few weeks of his life.  On 23rd July Mr H had a fall at home, and whilst medical assessment was sought from the GP Mr H was deemed as not requiring hospital admission. He was however, eventually placed in a nursing home as he was unable to meet his care needs.  Mr H resided at the nursing home from 28th July to 2nd August when due to a deterioration in his condition he was admitted to hospital. Mr H died in hospital four days after admission. His cause of death was recorded as bronchopneumonia and fractured vertebra with spinal cord compression.  The SCR focused on the failure of professionals to monitor his conditions and to seek appropriate medical help for the significant injuries he had sustained.

Professional learning:

  • Knowledge and insight of family members and carers about their relatives should be carefully listened to by clinicians.
  • Nursing staff observations about how patients present over a 24 hour period can significantly influence medical diagnoses, treatment plans and decisions about investigatory processes, such as x-rays. It is essential that these observations are reliable and properly recorded by the relevant member of nursing staff
  • Delays were caused partly through inefficient communication within the nursing home and between the nursing home and the GP practice. Poor standards of recording of assessment and referral information were also contributory factors.
  • Where there is evidence of confusion, professionals should proactively consider the possibility that the patient may lack capacity to make informed choices about their admission, care and treatment plans.
  • Patients who have mental capacity may still benefit greatly from professionals actively involving family members, to ensure that the patient’s wishes are properly understood, recorded and acted upon. This is particularly true when there is evidence that the patient is experiencing periods of confusion and disorientation.
  • Close working relationships, based on professional trust and respect between GP practices and nursing homes, deliver real benefits to residents and should be actively encouraged and supported.
  • However, such relationships should not become so informal that they come to rely exclusively on informal relationships between individuals, even where trust has been developed over a long period of time.

2012 May Serious Case Review regarding Mr H (Northumberland)

Winterbourne View (South Gloucs)

Winterbourne View Hospital was a private hospital for adults with learning disabilities and autism, mostly accommodating patients who were detained under the provisions of the Mental Health Act 1983.  An undercover reporter secured employment as a support worker at Winterbourne View Hospital. During his five weeks as a Castlebeck Ltd employee he filmed colleagues tormenting, bullying and assaulting patients. Fundamental principles of health care ethics such as respect for autonomy, beneficence and justice were absent at Winterbourne View Hospital. Undercover Care: The Abuse Exposed recalled the long-stay NHS hospitals for adults with learning disabilities. Unlike such institutions however, Castlebeck Ltd, was not starved of funds. In 2010, Winterbourne View Hospital had a turnover of £3.7m. Information from Castlebeck Ltd was not transparent enough to know how much was transferred to Winterbourne View Hospital’s expenditure budget.

2012 Serious Case Review regarding Winterbourne View (South Gloucestershire)

Gemma Hayter (Warwickshire)

Twenty-seven year old Gemma Hayter’s body was found on 9 August 2010 on a disused railway line in Rugby. Her murder and the abuse that she suffered beforehand were truly abhorrent, committed by people she believed to be her friends. The five people who caused her death have been prosecuted three of whom are serving sentences for murder and two for manslaughter.  Gemma was a vulnerable adult who was known to a number of agencies throughout her life. Warwickshire Safeguarding Adults Partnership Board commissioned a Serious Case Review to examine in detail the way that services worked with Gemma and to make recommendations to better safeguard individuals in the future. The report concluded that while there was no evidence that Gemma’s murder could have been prevented or predicted, if she had received and accepted better support, she may have lived a better life and been less likely to fall into the company of people who presented serious risks. Though there was evidence that she was regularly exploited by people who knew her and she was known to many agencies, no single agency had a full picture of her life and the level of risk she was exposed to. This case raises wider issues nationally about community safety for single adults who may be vulnerable to disability based harassment, hate or mate crime and exploitation.

Professional learning:

  • The need for community safety strategies to address disability based harassment, hate or mate crime and exploitation.
  • The need for awareness, information and guidance on mate crime.
  • Risk assessments to be undertaken routinely and used to underpin decision-making in relation to undertaking reassessments and the closure of cases.
  • The importance of strategies to help manage disengagement of service users from services.
  • Recognition that the safeguarding process  and the threshold of significant harm relies on the presence of a single large trigger and fails to identify people at risk in the community where the evidence is through a larger number of low level triggers.
  • The need to work preventively in order to give people living in the community, and may be vulnerable to mate crime, the skills to keep themselves safe.
  • The need for a systematic approach by agencies to give or request feedback following referrals or contacts to report concerns.

2011 October Serious Case Review regarding Jemma Hayter (Warwickshire)

MC (Northamptonshire)

MC had Down’s Syndrome, a significant level of learning disability, complex needs and suffered from epilepsy. He died unexpectedly whilst in hospital. MC had been living in residential care since 1994. At the time of his death, he resided in a residential care home in Northamptonshire and his daily care was, therefore, provided by the carers employed at the residential facility where he lived. MC had originally been a resident of Hertfordshire who had placed him in the residential home in Northamptonshire and also continued to be the responsible funding authority. Hertfordshire therefore, retained the care management responsibility for MC. MC had contact with primary care services, outpatient contacts at the local hospital involving three admissions over the course of October and November 2009. He died in Kettering General Hospital on 29 November 2009. The hospital carried out an internal review, to examine the unexpected death and consider whether reasonable adjustments had been made given MC’s communication and mental capacity issues.

Professional learning:

  • Guidance should be provided to professionals on identifying and raising safeguarding issues in regulated settings, including hospitals.
  • Safeguarding investigations should consider the risks posed to other vulnerable adults, in any given situation and not just risks for those who are the subject of the investigation.
  • Individual workers should have access to clear information explaining how to escalate concerns about care within or across agencies, where concerns initially raised are not acted upon.
  • Guidance should be provided about how safeguarding investigations apply where the individual has died. This should include issues of pace, considerations of other potential victims and the role of the police in investigating these situations.
  • Procedures should clarify how the safeguarding process relates to any internal management/serious incident reviews undertaken regarding the case and to ensure these run in parallel with the interfaces between each managed effectively.

2011 October Serious Case Review regarding MC (Northamptonshire)

Case 04 (Worcestershire)

04, was a female Lithuanian national, who had been living and working in the area since May 2010. At around 10.00 am on Thursday, 23rd September 04 was found asleep in the gardens of a public house in Worcestershire. Staff from the public house observed her for several hours but when roused it was evident that she was drunk, and about 2.00pm they called an ambulance. She refused to be medically examined and talked about jumping in the river. The police were then called to the scene as 04 appeared to be still suffering from the effects of alcohol. She told the officer that she wanted to kill herself. She had facial injuries, which she then attributed to a road traffic accident a few days previously.  The Police decided to detain 04 under Section 136 of the Mental Health Act 1983, (amended 2007), at 14.45 and she was taken to the Police Station, as a place of safety. She was seen by the Force Medical Examiner who contacted the on-call Approved Mental Health Practitioner. It was agreed later that evening that an assessment was not required and that the Police should discharge her if they had no further concerns when she was sober the next day. O4 was discharged from Custody at about 9.00am on the morning of the 24th September when she was deemed sober and rational. She was released and directed to the railway station as she stated that she wished to visit friends in London. Later that afternoon she was seen on CCTV recordings wandering around the railway station, drinking from a bottle, for about 2 ½ hours. She was asked to leave the station and was escorted from the premises, as she was intoxicated. Shortly afterwards she was seen on the CCTV images entering the Ladies Toilets at the Station and 15 minutes later was found hanging by the neck inside a toilet cubicle. Despite attempts to resuscitate her she was pronounced dead at the scene.

Professional learning:

  • All relevant professionals must be aware of their duty to undertake a Mental Health Assessment of all persons detained under the Section 136 of the Mental Health Act 1983, (amended 2007), in line with the Mental Health Act Code of Practice. Individual professional responsibilities following the discharge of the Section 136 should be clarified and actions recorded.
  • Decision making and actions related to the section 136 process must be clearly documented.
  • Community Safety should work with partners to produce an information pack or booklet initially for transient workers in local employment. Such a pack would be given to them on commencement of their employment and would include details such as how to register with a GP and other local services and information.

2011 November Serious Case Review regarding 04 (Worcestershire)

Fiona Pilkington (Leicestershire)

Fiona Pilkington killed herself and her severely disabled daughter Francecca Hardwick in 2007, after 10 years of torment by local youths.  The Independent Police Complaints Commission (IPCC) carried out an investigation published in May 2011 which concluded that the failure by police officers to identify Fiona Pilkington, her son and daughter as a collective vulnerable family unit was at the core of Leicestershire Constabulary’s failure to implement a cohesive, structured and effective approach to the harassment/anti-social behaviour from which they were suffering. The report lists 33 recorded incidents between November 1997 and October 2007 when the family had contact with Leicestershire Police. Incidents were often dealt with in isolation and with an unstructured approach which prevented a true picture of the level of harassment suffered by family.  The report also identified that the Police failed to recognise and address the difference between general anti-social behaviour and harassment.  The Serious Case Review questioned the ability of safeguarding adult policies to protect vulnerable victims of antisocial behaviour given that policies based on the current No Secrets guidance could be leaving people who were not eligible for social care services “at risk of falling through the safeguarding net”.  An inquest jury criticised Leicestershire Police for failing to respond to Pilkington’s complaints and also the local councils responsible for tackling antisocial behaviour where the family lived.

Professional learning:

  • The importance of offering a safeguarding response even if the vulnerable person is not eligible for services.
  • The importance of distinguishing between general anti-social behaviour, harassment and hate crime.
  • The need for clear thresholds for safeguarding adult referrals which, if breached, should always result in contact with the council adult social care services.
  • Risk assessment and risk management strategies to be based on full information outlining repeating and escalating patterns of incidents rather than each treated individually.
  • The need for a multi –agency response to such cases e,g, the use of MARAC or safeguarding adults procedures as appropriate.

2009 Fiona Pilkington (Leicestershire)