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)

Mr C (Buckinghamshire)

During February 2010, the dismembered body of 70 year old Mr C was found under concrete in the back garden of his home. In September 2010, Mr C’s son, who was a 22 year old undergraduate, was found guilty of his father’s murder. The Thames Valley Police had become concerned that between August 2008 and February 2009, when all contact with this older man had ceased, neither the NHS nor Adult Social Care raised concerns about Mr C who was a Direct Payments Recipient. In the absence of information to the contrary, both Adult Social Care and the support agency commissioned to support all Direct Payments Recipients believed that Mr C employed Personal Assistants. However, the police were unable to trace them. Also, it has become subsequently apparent that Mr C’s son might have fallen within the statutory definition of a carer but there was no evidence that he had been recognised as such by either the NHS or Adult Social Care.

Professional learning:

  • This Serious Case Review highlights flawed practices in Buckinghamshire’s Adult Social Care with regards to the oversight of Community Care Assessments and Direct Payments. The police investigation and murder trial revealed more of the complicated father-son relationship than was known by Adult Social Care. Mr C was a complex 70 year old with an array of health support needs and yet his circumstances were not deemed to merit anything other than a passive and remote degree of social work oversight.
  • Valuable information was not committed to records. Regrettably, social worker expertise was not deployed – not even in a professional advisory capacity.
  • Irrespective of a Community Care assessment, remarkably little was known about Mr C, or his son’s care-giving. It appears that the way that social workers undertook their role meant that it promoted access to Direct Payments without professional challenge as to need, appropriateness or outcome. Their role appeared to be reduced to that of administrative approval.
  • The son’s willingness to assume care-giving responsibilities for his father was not verified.
  • The lack of scrutiny of Mr C’s care presents a stark picture. Policies and procedures which were in place to audit public expenditure were not followed.
  • Care appeared to operate under the assumption that what was agreed would occur. It appears too that Mr C was regarded as a client with a less complex care package and, as such, was subject to a light-touch reviewing process captured via arms-length recording.
  • This Serious Case Review highlights major shortcomings in the oversight of public funds by Buckinghamshire Adult Social Care. It appears that Mr C received Direct Payments which he did not use for the purposes intended. In turn, his son continued to access these monies.

2011 May Serious Case Review regarding Mr C (Buckinghamshire)

Alice Porter (Northamptonshire)

On 20th April 2011 Alice was being accompanied by Mencap staff to attend church when she fell. The Mencap staff called an ambulance and, despite some initial discussions about whether to take Alice home, the ambulance crew took her to hospital for assessment. Alice was admitted to Northampton General Hospital on 20th April 2011, where she died on 26th May 2011. Alice was 54 when she died. Serious concerns were raised about the care and attention Alice received from both East Midlands Ambulance Service and Northampton General Hospital in the time between her fall and her death. Northamptonshire County Council received three safeguarding alerts regarding Alice’s care while Alice was in hospital. Northampton General Hospital undertook a serious incident investigation and the findings from this and from the safeguarding investigation were considered by an Adult Safeguarding Case Conference on 27th July 2011. EMAS also undertook a serious incident investigation and the case conference found neglect in respect of both East Midlands Ambulance Service and Northampton General Hospital. The circumstances of Alice’s care were escalated to the Northamptonshire Safeguarding of Vulnerable Adults Board who decided that a serious case review should be undertaken, to understand the reasons behind a failure to meet Alice’s care and clinical needs and to learn lessons to improve services going forward.

Professional Learning:

  • Communication – both internal communication and with Alice and her family and carers
  • Failure to make reasonable adjustments which negatively impacted on the diagnosis and treatment plan for Alice.
  • Failure to properly apply the Mental Capacity Act and make best interest decisions.

These are the same themes that run through the plethora of research documents and inquiries into the health care of people with learning disabilities that have been published over recent years. While it is recognised that these publications have largely been in respect of the ongoing health care needs of people with a learning disability and access to services, it is suggested that the findings could also be applied to emergency interventions. There is resonance with Alice’s experience in particular findings of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD), March 2013 which are summarised as follows:

  • Delays or problems with diagnosis or treatment; problems with identifying needs and providing appropriate care in response to changing needs
  • The lack of reasonable adjustments to facilitate healthcare of people with a learning disability, particularly attendance at clinic appointments and Investigations
  • GP referrals commonly did not mention learning disabilities and hospital “flagging” systems to identify people with learning disabilities who needed reasonable adjustments were limited
  • Professionals in both health and social care commonly showed a lack of adherence to and understanding of the Mental Capacity Act 2005, in particularregarding assessments of capacity, the process of making “best interest” decisions and when an Independent Mental Capacity Advocate (IMCA) should be appointed
  • Despite numerous previous investigations and reports, many professionals are either not aware of, or do not include in their usual practice, approaches that adapt services to meet the needs of people with a learning disability
  • There is a continuing need to identify people with learning disabilities in health care settings and to record, implement and audit the provision of “reasonable adjustments” to avoid serious disadvantage
  • Communications within and between agencies need to be improved It is evident, and it is acknowledged, by those involved in Alice’s treatment

2011 July Serious Case Review regarding Alice Porter (Northamptonshire)

Summer Vale (Leicestershire)

The abuse described in the BBC documentary, ‘Can Gerry Robinson Fix Dementia Care Homes?’ was one of the reasons for having a Serious Case Review. Summer Vale Care Centre was a home for 26 people with dementia and/ or mental disorder, until it closed in October 2009. Nine agencies, including the home’s owner, Minster Care Management Ltd., prepared information about events that led up to the disclosure of sexual assaults in the home. The Serious case Review has found that Summer Vale Care Centre did not ensure the safety of its residents; although the exact number of abusive incidents in the home is unknown, a dismal picture of the lives of residents emerged; a woman who was a National Health Service Continuing Healthcare funded patient was repeatedly physically and sexually assaulted; there were lots of incidents and concerns and even though there were around 60 professionals involved in making sense of this information, all of whom agreed that something should be done, no one asked searching questions and no one assumed a lead role; Summer Vale Care Centre did not train or supervise its staff; those who asked the home to provide placements and those who inspected it believed the home’s managers when they said that they were “monitoring” residents who were either violent and harmed people sexually or were the victims of assaults.

Professional learning:

  • Safeguarding alerts should use unequivocal – as opposed to coded – language, most particularly when these concern sexual assaults;.
  • Resident-on-resident abuse should be reported and acted upon as a matter of urgency.
  • Safeguarding investigators should receive training in order that the functions of “monitoring,” and “risk assessment” and “risk management,” across sectors, are fully understood.
  • Safeguarding should be a central focus of commissioning and contract activity.
  • NHS commissioners, managers and clinicians, most particularly in primary and Continuing Healthcare, be required to receive training in order to be aware of their responsibility to support and protect vulnerable adults in any service, especially those that are failing and to ensure they know how to report concerns.
  • Assessment and admission practices in their homes to be subject to on-going scrutiny.
  • Universities and colleges responsible for the professional training of students (medical, nursing, social work, psychology and therapies) should be familiar with safeguarding procedures and report on all concerns raised by students in their placements.

2010 Serious Case Review regarding Summervale Care Home (Leicestershire)

Adult X (Nottingham City)

Adult X died in summer 2009 of natural causes as a result of sudden death in epilepsy (SUDEP).The Serious Case Review found that there were a number of areas where services could be improved.

Professional learning:

  • The need for much improved communication and information sharing across agencies.
  • A need for increased awareness of adult safeguarding was highlighted for almost all staff groups.
  • Young people and vulnerable adults need to be placed at the centre of assessments and care plans and their views actively sought.
  • A Transition Policy and Procedure is required for young adults moving from Children’s Services to Adult Services.
  • A greater level of understanding across agencies is needed in relation to Sudden Unexpected Death in Epilepsy (SUDEP) when working with individuals who experience epilepsy.

2010 SCR regarding Adult X (Nottingham City)

A1 (Worcestershire)

At the time of his death A1 had been known to local mental health services since at least 2002 and had been treated for depression, anxiety, and behavioural problems. There had been a diagnosis of paranoid schizophrenia earlier in his clinical history. He also suffered from chronic gastric problems and was well known to his General Practitioner. A1 rented a housing association bungalow in Evesham but had been living with his 88 year old mother for nearly a year before his death. A1’s mother was admitted to hospital in late December 2008 and following a multi-agency safeguarding meeting it was agreed with A1’s family that he should return to his own bungalow before his mother’s discharge from hospital. This meeting had been held under local safeguarding procedures owing to the mother’s vulnerability and concerns having been raised about A1’s behaviour and its impact on his mother.  A1 was visited at his bungalow by the local Community Mental Health Team following the move and was also assessed for home treatment. He was considered to have sufficient mental capacity to live independently. He was last visited at home by a number of health professionals before his death but then missed a number of subsequently routine out-patient appointments. Neighbours and a utility service worker became concerned and A1’s body was discovered at home by the Police on 25th March 2009. The cause of death was later recorded by the Coroner as “pneumonia, paranoid schizophrenia and inanition”.

Professional learning:

  • Policy and practice guidance should clarify and facilitate family involvement and information sharing so that the privacy of the individual is not compromised but neither is their vulnerability increased by barriers being placed in the way of open information sharing by family members.
  • Family members, their relationship and role in caring for known patients and clients should be clearly recorded as part of a mental health Standard Care Assessment. Consideration should then be given to whether they need to be proactively contacted by professionals as part of intervention.
  • Any family members identified who are providing care or substantial support should be offered a Carers Assessment.
  • There should be clear thresholds in place to assist in identifying when a multi-agency approach should be used where there are serious concerns but the case falls short of safeguarding procedures. Such cases should have management oversight.
  • Safeguarding training strategies should include provision on managing self-neglect.
  • The LSAB should develop clear links between the Coroner’s office and safeguarding teams.

2010 April Serious Case Review regarding A1 (Worcestershire)

DN (Solihull)

DN moved to the area in 2004 from another part of England to be nearer to her son and family. She had a range of serious health problems including osteoporosis, severe deafness, very impaired sight, rectal prolapse and hypertension. Her physical and her mental health had deteriorated over the years. She died in February 2009 aged 96. Her death certificate stated that she died from vascular disease. In January 2009, just three weeks before her death, during concerns came to light about her care at the home, specifically about the severity of a pressure sore on her heel. A safeguarding investigation was carried out and it was assessed that DN a nursing home placement to meet her increasing health needs. She moved in distressing circumstances to a nursing home two days before she died.  One of the overall lessons from this SCR is that caring for potentially vulnerable people in a way that enables them to maintain control over as many aspects of their life as possible, whilst at the same time keeping them, and the staff who are involved with them safe, is an extremely complex task.

Professional learning:

  • Clear policies and procedures are needed to manage
  • end of life care and to consider what extra supports may need to be made available to homes to enable residents to die ‘at home’.
  • Alignment between individual safeguarding investigations and large scale reviews of provider services is required to ensure individual vulnerable people are not lost in the process.
  • To ensure advocacy, both general advocates and Independent Mental capacity Act Advocates (IMCAs) are used appropriately in safeguarding proceedings.

2010 February Serious Case Review regarding DN (Solihull)

Mr S (Central Bedfordshire)

Mr S died on 24 February 2009 following re-admission to hospital from a home where the Coroner described the nursing care as “woefully inadequate”. The Coroner determined that Mr S ‘whilst incapacitated by rapidly deteriorating physical and mental health, died on this date for want of care by those charged with it.” In response to the concerns raised about the care home in question, the Council conducted a review of the support received by all residents of the home, and suspended the funding of places there until satisfied that acceptable standards were operating. The regulator (the then Commission for Social Care Inspection) was fully involved in this process. The Serious Case Review panel identified issues with the quality of community care assessments; inconsistent standards for assessment, care management and support for self- funding service users compared to those who were publically funded; irregular on the part of the provider.

Professional learning:

  • In Serious Case Reviews, where there is to be a Coroners inquest, discussion should take place with the Coroner about the timing and scope of the review.
  • Any Safeguarding Investigation following the death of a vulnerable adult should consider at an early stage if it would be appropriate to offer support to the family/carer either through involvement of a statutory agency or other recognised body.
  • The Crown Prosecution Service should identify a lead prosecutor for cases involving vulnerable adults.

2009 Serious Case Review regarding Mr S (Central Bedfordshire)

Mr R (Central Bedfordshire)

Mr R was an 87 year old man who suffered a CVA and was admitted to Luton and Dunstable Hospital on 29th June 2008. A care management assessment was undertaken on 21st July 2008 which identified that Mr R was predominately bed/chair bound and was totally dependent in all aspects of care requiring hoisting by two people to transfer from bed to chair or commode. He required full assistance with washing, dressing and toileting, supervision when eating and when taking his medication. Mr R was incontinent. The outcome of the assessment was that Mr R needed 24 hour residential care and support. Mr R was discharged to a care home where he remained until his admission to Luton and Dunstable Hospital where he died on 23rd November 2008. The cause of death recorded by the Coroner was sepsis, pressure sores, historical illness, and stroke. In response to the concerns raised about the care home in question, the Council conducted a review of the support received by all residents of the home, and suspended the funding of places there until satisfied that acceptable standards were operating. The regulator (the then Commission for Social Care Inspection) was fully involved in this process.

Professional learning:

  • Tissue viability issues should be considered, particularly when any assessment or reviews are undertaken. Staff should receive training relevant to their professional needs about tissue viability.
  • If a resident of a residential care home develops a pressure sore then a risk assessment and review must be undertaken as well as a safeguarding referral.
  • As part of the safeguarding procedure consideration needs to be given to acquiring detailed case records of individuals in residential or nursing home care in order to assist in any subsequent SCR.
  • The Safeguarding Adults Board should seek to establish a Safeguarding Adults champion with the CPS.
  • There should be GP representation for all  SCRs.

2009 Serious Case Review regarding Mr R (Central Bedfordshire)

A and B (Kent)

Case 1 involved Mr A an older man with a history of Parkinson’s Disease who, after receiving respite care several time was admitted to a care home. At the time of admission he had no skin care problems but he was unfortunately injured as result of being left sitting next to an unguarded radiator that was faulty and dangerously hot. He was taken to the A&E Department and later saw a District Nurse who assessed him as having a high risk of developing pressure sores. There were delays in ordering pressure relieving equipment, collecting special dressings that were prescribed or seeking expert advice. He was then transferred to another home but the hand-over was not well coordinated and DN records were not transferred with him, so that his wounds continued to trouble him and he became emaciated and unwell: the pressure sore that had previously developed worsened. As he became more unwell and dehydrated; he either refused or was not administered his medication for Parkinsons, record-keeping was patchy and he was eventually admitted to hospital in a very poorly state six weeks later by which time his pressure sore was assessed as having reached grade 4. The second case concerned Mrs B an older woman, living in a care home who had dementia and towards the end of her life became bed-bound. She also developed pressure sores that became infected, received inadequate pain relief and suffered unnecessarily. Her situation was of particular concern as lessons should have been learned by the home after the death of the first client just 8 months previously. An anonymous whistle-blower sent letters and photographs suggesting that the quality of care at one of the care homes was below standard. The safeguarding alert, raised by the District General Hospital at the time of the first admission, led to the contract being suspended by Kent County Council and placements were stopped for a period of 3 months. The quality of care in were summed up in the following terms: “Serious failings were found. There was no wound assessment or evaluation. Records of dressings were intermittent and inconsistent. Documentation was generally poor with little evidence of what care had been given. Fluid balance charts were kept (though poor) but these were not acted upon”.

Professional learning:

  • Contracts should emphasise the requirement for staff to have the right skills to provide care including adequate written and spoken English.
  • Staff from BME communities should be supported to develop skills and helped to access information about particular conditions alongside other members of the staff team.
  • Anonymous information should be treated as intelligence and investigated or followed up without exposing whistleblowers or allowing others to cover up serious failings.
  • A post incident action plan should be agreed for services identified as having significant deficits setting out the improvements required and timescales.
  • Contracts and commissioning activity should support the safeguarding process for example, by implementing contract compliance and defaults measures and sanctions.
  • In such circumstances, NHS investigations should be undertaken under the auspices of the LSAB’s Safeguarding Process.
  • If a vulnerable adult who has been the subject of a safeguarding alert dies in hospital, a Police report should always be considered to explore whether neglect or mistreatment contributed to their admission or to their death.

2009 April Serious Case Review regarding A and B (Kent)

Mrs A (Worcestershire)

Mrs A’s body was discovered on 30 October 2009 in the grounds of her residential home A. Post Mortem revealed the cause of death to be hypothermia. Mrs A was an elderly person suffering with vascular dementia who received a range of health and social care services. In the terms of the Worcestershire Safeguarding Adults Protection Policy, she was a “vulnerable adult”. Mrs A was initially referred to Worcestershire’s Mental Health Services in September 2007 by her GP. He was concerned that she was experiencing problems with her memory and becoming disoriented and confused.  Mrs A resided at the care home for 2 weeks until she was found dead in the grounds of the Home on 30th January 2009. Post Mortem revealed that she had died from hypothermia. The Individual Management Review provided by the care home noted that on the evening of 29th January a fire door was found to be open. This was reported to a member of maintenance staff who secured it again. According to the report, the senior carer on duty failed at that point to conduct a headcount of residents. Further, during the night the senior carer on duty failed to check on Mrs A as was required by her care plan. It was discovered that she was missing the next morning.

Professional learning:

  • Staff should offer a carers assessment to main carers.
  • Arrangements are needed to ensure the continuing management of physical health conditions is not overlooked when a change in placement is made to address a mental health need.
  • Mental capacity assessments are undertaken when necessary and are appropriately recorded.

2009 October Serious Case Review regarding Mrs A (Worcestershire)

JK (Cornwall)

JK was discovered dead in her home on 12.11.08 by members of the Rapid Assessment Team (RAT). JK suffered from a range of health needs but was able to mobilise inside her home using a zimmer frame. She was assessed as able to manage her own personal care and meals and relied on friends to undertake her shopping. However she chose not to go outside her property, and was known to spend the main part of her day on her bed with her three dogs. It is reported that there were no concerns that she lacked mental capacity and her decisions to lead this lifestyle. In the years before her death there were a number of reports regarding the poor state of hygiene in the house and the presence of dog faeces on the floor. A number of agencies were involved with JK in the week immediately prior to her death.

Professional learning:

  • Assessments and care plans should have a service user focus rather than reflect the available service and interventions.
  • Assessments and care plans should address issues of reluctance to engage with services.
  • Multi- disciplinary meetings (as part of business as usual) should be held when there are concerns about a vulnerable adult.  A key worker should be identified to co-ordinate the shared plan.
  • Thresholds to indicate when circumstances of self-neglect tip into safeguarding.
  • Clear and robust record keeping of decisions and actions taken.
  • Feedback provided to referrers on outcomes and actions following alerts/referrals.
  • Monitoring of how often service user refusal to accept services to detect repeating and escalating patterns.
  • Guidance should be provided for practitioners on approaches to working with vulnerable people who refuse services and/or at risk of self-neglect.   

2009 June Serious Case Review regarding JK (Cornwall)

Adult X (Cornwall)

On 1st March 2007 a 43 year old woman was admitted to hospital via an ambulance which she had called. She was found to have a fracture to the neck of her left femur and was referred for orthopaedic treatment.  Following surgery she was also treated for alcohol withdrawal but deteriorated and had a fit. She was transferred to the Intensive Therapy Unit where the diagnosis was Hepato-Renal Failure, Alcoholic Liver Disease and left fractured neck of femur (infected). She died on 12th March 2007 having never regained consciousness with the medical cause of death being established as liver failure, alcohol cirrhosis, renal failure and septicaemia in addition to the infected fracture. A Police investigation resulted in a file being submitted to the Crown Prosecutor who decided that no proceedings could follow.

Professional learning:

  • Every professional has a duty of care to an individual and that this duty cannot be discharged through another individual or agency without a formally recorded agreement.
  • All agencies should be invited to attend a multi-agency meeting in respect of a potentially vulnerable adult if their expertise could contribute to a positive outcome (regardless of the agency’s prior or current involvement with the client).
  • Safeguarding should be considered as part of the core assessment processes of all agencies.

2008 Serious Case Review regarding X (Cornwall)

Adult X (Worcestershire)

X was well known to local services for many years. During the period under review he lived at home with his mother, step-father and three half-brothers. He was born with severe learning disabilities. Throughout his life he was unable to talk or care for himself and he suffered from epilepsy. X continued to require residential and day care as he became an adult. The care package agreed for him included day care and respite care. During the second half of 2007, X ceased attending one of his day care and by November 2007 his attendance at his second placement had reduced. In addition, staff were concerned at his apparent weight loss and these were eventually reported to the Learning Disability Team. On December 19th 2007 these concerns were formally reported to a senior member of the Learning Disability Team. No action was taken by the Team until January when phone calls were made to his mother who was X’s main carer. She assured that X would be taking up his place again. In the event X did not attend again. On March 19th 2008 Team made a visit to X’s home but again was unable to see him. This was followed by a further visit on April 4th at which the worker spoke to X’s mother. Subsequent efforts were made to establish X’s condition and whereabouts. On April 23rd 2008 X’s body was discovered in the back garden of the family home. He had been dead for some time. This followed the discovery of the body of X’s mother on April 21st elsewhere.

Professional learning:

  • Concerns or anxieties about a vulnerable adult should be reported immediately however ‘low level’ or uncertain.
  • Those responsible for action under Safeguarding Procedures must make an adequate and rigorous assessment of reported concerns within agreed timescales. Recording of meeitngs and actions taken should be robust.
  • Care should be well co-ordinated based upon effective assessment and reviewed annually.
  • Carers must be informed of their right to a carers’ assessment.

2008 December Serious Case Review regarding Adult X (Worcestershire)

Hounslow Ruling (Hounslow)

A High Court ruling in which the local authority was ordered to pay damages to a vulnerable family who had been abused by a gang of youths.  This judgement concerns a claim for damages brought by a married couple with learning disabilities against Hounslow for negligence and breach of duty of care on the part of the local authority. They claimed the local authority failed to move them from their home using its emergency transfer procedure which could have prevented them being subject to a horrific incident in their own home.  They also were claiming damages under the Human Rights Act, 1998 (sections 6 and 7) from the local authority because it failed to protect them from inhuman and degrading treatment, and to maintain the integrity of their private and family life, thus breaching Articles 3 and 8 respectively of the European Convention on Human Rights.

Steven Hoskin (Cornwall)

Steven Hoskin’s body was found on 6 July 2006 at the base of the St Austell railway viaduct. In addition to the catastrophic injuries associated with falling 30 metres, a post-mortem examination found that Steven’s body bore evidence of torture: cigarette burns, neck bruises from the dog collar and leash he had been dragged around in, a lethal dose of paracetamol and alcohol, and footprints on his hands which finally caused him to fall to his death. Steven was a vulnerable adult, whose needs were well known to the local NHS, council adult care services and housing services. Many months before his murder, Steven was “targeted” by one of the perpetrators, Darren Stewart (also a vulnerable adult) who had recognised his vulnerability and ‘moved in’ on him. In the year and a half before Steven’s murder, Darren Stewart made many calls to ambulance service and by January 2006, the ambulance service knew Darren was dangerous and had a “warning marker” against him and so had requested police attendance at all emergency visits. Although Steven was known to have a learning difficulty, the excessive use of emergency services by someone residing.

Professional learning:

  • Awareness and understanding of wider professionals of their role in safeguarding.
  • Clear “thresholds” needed in the NHS and other agencies for safeguarding adult referrals (as there are for children) which, if breached, should always result in contact with the council adult social care services.
  • The importance of safeguarding interventions regarding vulnerable adults who abuse.
  • The importance of timely information sharing in order to identify risk and intervene at an earlier stage.

2007 December Serious Case Review regarding Steven Hoskin (Cornwall)

Adult X (Lincolnshire)

X had Epilepsy and Autism Spectrum Disorder (ASD). His family home was in Nottingham, but his parents took the decision that he would be better cared for in specialist accommodation. Accordingly, during 1996 he became resident at a specialist residential unit in Lincolnshire. Following several seizures in 2006 his usual prescribed medication (Epilim) was supplemented by Keppra which should have been administered twice each day at 9am and 9pm. On Saturday 2 September 2006 night staff completed an entry in a handover/communication book indicating that X was about to run out of Keppra. No immediate steps were taken to obtain further supplies and records show that at 2100 on Sunday 3 September 2006 X had his last dose of Keppra. At 0910 on Wednesday 6 September 2006 he was found dead in bed. By this time he had missed four doses of Keppra and had been due a fifth at 0900 that day. An inquest jury later concluded that the failure to provide Keppra had materially contributed to his death. The jury also decided that systemic failures in relation to stock keeping, record keeping, and a lack of sufficient training, communication and vigilance by staff to follow policy and procedures had all contributed to the death.

Professional learning:

  • Staff in management/supervisory roles should be appropriately supervised.
  • Staff in management/supervisory roles should be suitably qualified, inducted and trained to fulfil their responsibilities.
  • Clear procedures and training for staff involved in the administration of medication.
  • When service users are placed in other local authority areas, the host authority should be informed of the placement.
  • Annual reviews of placements within other authorities should take place and that information from the host authority forms a part of the review of care arrangements.
  • In the event of a serious incident within a care setting, multi-agency procedures should be promptly instigated with a focus on investigating adult safeguarding concerns and safeguarding other service users.
  • Where a serious incident within a residential care setting occurs, placing authorities should be informed at an early date. A thorough assessment of risk should include the desirability or otherwise of also informing the families/carers of service users.

2006 September Serious Case Review regarding X (Lincolnshire)

Cornwall Partnership NHS Trust

Cornwall Review (2006): Joint investigation into the provision of services for people with learning disabilities at Cornwall Partnership NHS Trust.  The investigation found that institutional abuse was widespread, preventing people from exercising their rights to independence, choice and inclusion. One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection. More than two-thirds of the sites investigated placed unacceptable restrictions on people living there. For example, some internal and external doors were kept locked by staff to restrict the movement of people from the services, instead of seeking alternative methods to address perceived problems. In one home, taps had been removed and, in another, light fittings were taken out. The finances of people in supported living services were poorly managed e.g. the pooling of money to a shared household account and the use of people’s money to purchase communal goods and pay for improvements to homes.  There was evidence of physical restraint being used illegally and excessive use of PRN medication to control behaviour.  One person spent 16 hours a day tied to their bed or wheelchair, for what staff wrongly believed was for that person’s own protection.

2006 Joint Investigation into Cornwall Partnership NHS Trust