Learning from Experience Database - Serious Case Reviews

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AB (Kent)

This review focused on the investigation into allegations made against a care worker AB working in an NHS Trust care home for adults with a learning disability. The allegations included physical, psychological abuse and neglect which taken together could rightly be described and institutional abuse. The police voiced concerns that alleged practices did not appear to have been addressed appropriately by the management. Specific allegations concerned 5 named residents and occurred over approx 2 years. Following police investigation AB was charged under section 127 of the Mental Health Act 1983. The charges were later dropped by the CPS just before the case was to be heard in the Crown Court. The reason given for this action was that although the charges could probably have been proven, it was considered not to be in the public interest to prosecute this care worker when more senior staff and managers who had failed to deal with the abusive behaviour had not been prosecuted.

Professional learning:

  • Investigations into institutional abuse must begin with a proper scoping exercise so that the role of management in the aetiology of any specific reported incident is included in the purview of the investigation and its outcomes.
  • Preparation for disciplinary hearings should be undertaken in consultation with and in tandem to the Police investigation.
  • Advocacy should always be available to vulnerable adults in safeguarding investigations. IMCA’s should be provided in cases of this kind where individuals qualify for assistance in making major decisions about accommodation, serious health care or in the wake of abuse if they are un-befriended, or if their family are seen to be acting against their best interests.
  • Standards in services that are designated for re-provision must not be allowed to fall below acceptable standards or to evade regulatory activity in respect of current provision.
  • Liaison between CPS and Police during investigations should be stepped up and include proper debate about the scope of investigation and the potential negligence of management, and/or appropriateness of corporate negligence as well as not, instead of, individual charges.
  • Joint SCR or Serious Untoward Incident Reviews, managed jointly within the Safeguarding Adult multi-agency procedures should be carried out when abuse is uncovered in NHS facilities.

2005 Serious Case Review regarding AB (Kent)

Shipman Public Inquiry

Harold Shipman was convicted at Preston crown court in January 2000 of the murder of 15 elderly patients with lethal injections of morphine. A public inquiry was launched in June 2001 to investigate the extent of his crimes, how they went undetected for so long, and what could be done to prevent a repeat of the tragedy. A total of 250 murders of patients were ascribed to Shipman over a 23 year period.  An independent public inquiry into the issues arising from the case of Harold Shipman was conducted after his trial.  This was chaired by Dame Janet Smith and was split into two parts. The report of the first part examined the individual deaths of Shipman’s patients. The second part examined the systems in place that failed to identify his crimes during the course of his medical career. The inquiry team also carried out a separate investigation into all deaths certified by Shipman during his time as a junior doctor at Pontefract General infirmary between 1970 and 1974.

Professional learning:

  • The inquiry has published six reports. The first concluded that Shipman killed at least 215 patients.
  • The second found that his last three victims could have been saved if the police had investigated other patients’ deaths properly.
  • The third report found that by issuing death certificates stating natural causes, Shipman was able to evade investigation by coroners.
  • The fourth report called for stringent controls on the use and stockpiling of controlled drugs such as diamorphine.
  • The fifth report on the regulation and monitoring of GPs criticised the General Medical Council (GMC) for failing in its primary task of looking after patients because it was too involved in protecting doctors.
  • The sixth and final report, published in January 2005, concluded that Shipman had killed 250 patients and may have begun his murderous career at the age of 25, within a year of finishing his medical training.

Bichard Public Inquiry

On 17 December 2003, Ian Huntley was convicted of the murders of Jessica Chapman and Holly Wells. In the days following Huntley’s conviction, it became clear that he had been known to the authorities over a period of years. In fact, he had come to the attention of Humberside Police in relation to allegations of eight separate sexual offences from 1995 to 1999 (and had been investigated in yet another). This information had not emerged during the vetting check, carried out by Cambridgeshire Constabulary at the time of Huntley’s appointment to Soham Village College late in 2001. A public inquiry was undertaken into child protection procedures, particularly the effectiveness of relevant intelligence-based record keeping, vetting practices and information sharing between agencies.

Professional learning:

  • This Inquiry led to the introduction of the POVA scheme and the vetting and barring provisions introduced through the Safeguarding Vulnerable Groups Act 2006.

D (Kent)

This case concerned a young man (D) who had profound physical and learning disabilities. He died in hospital, aged 27, from uncontrolled fitting exacerbated by other serious conditions. He had lived with his parents in impoverished and squalid surroundings. For much of the period reviewed, failure to act within a Child Protection framework was a significant factor in his ongoing experiences of inadequate care and serious neglect. It has raised questions about the way in which protection issues are managed within a transition planning process as Social Services did not interpret diffuse actions or failures to act as indications of continuing neglect and deprivation, which would have warranted definitive action. Health care professionals were confused about where the responsibility for decision-making lay and did not challenge actions which ran counter to D’s best interests. It is unclear whether the failure of his parents to seek out or comply with medical treatment contributed to his early death.

Professional learning:

  • Previous history of any safeguarding concerns should be passed to the GP to assist in diagnosis, treatment and discharge.
  • Child protection or child in need concerns should be central to the transition planning process.
  • A vulnerable adult is the primary client who should be at the heart of the protection process; legal action should actively uphold the vulnerable person’s human rights.
  • Medical, nursing and care management staff must be aware of best interest decision making and about the role of families and the formal decision maker.
  • Staff should be fully aware of the relevant parts of the Mental Health Act and Mental Capacity Legislation. In individual cases they should be fully briefed through the multi-agency arrangements to assist in professional decision making.
  • Safeguarding concerns must be taken into account in discharge planning from hospital settings.
  • Police need to be clear about responsibilities to use common, civil or criminal law to achieve safe outcomes for adults and children.
  • Staff must be fully cognisant of their powers and duties under a raft of legislation and avenues to achieve a safe outcome.
  • Staff should receive training in managing difficult personal interactions and in dealing with confrontation and conflict.
  • In extreme cases there should be contingency funds available so it is possible to seek additional legal or professional advice to support the safeguarding process.

2003 Serious Case Review regarding D (Kent)

Taywood House (Norfolk)

Taywood House was a residential care home in Great Yarmouth, which catered for approximately 14 residents, most of whom were funded by Norfolk Social Services. In August 2002 formal allegations of ill-treatment were made to the police and an investigation was commenced under inter-agency safeguarding procedures. During the investigation, it emerged that there may have been culpability for one or more deaths at the home and as a result, the investigation was escalated to become a major investigation (it should be noted that the investigation did not ultimately ascribe culpability for any death to any person).

In January 2003 a joint operation by Norfolk Constabulary, National Care Standards Commission and Social Services resulted in the arrest of the owners and the closure of the home as a result of the first successful application, nationally, to a Magistrates Court under s.20 Care Standards Act 2000. Whilst no charges were brought in relation to any deaths at the home the owners were prosecuted and in October 2004 they were convicted of the following offences:

  • Failure to conduct a business so as not to expose persons not in employment to risk. Section 3(1) and 33, Health and Safety at Work Act 1974
  • Ill-treatment or wilful neglect of persons who are mentally ill. Section 127(1) Mental Health Act 1983
  • Administration of a poison or noxious substance. Section 24 Offences Against the Persons Act 1861
  • Administering a medicinal product other than in accordance with the directions of an appropriate practitioner. Section 58(2)(b) and 67(2) Medicines Act 1968
  • One of the owners was sentenced to a term of 16 months imprisonment and the other to a term of 8 months imprisonment.

2006 Taywood Review Closing Report 31 3 06 Final

Margaret Panting (Sheffield)

A review into the death of a 78 year old woman from Sheffield who died after suffering “unbelievable cruelty” while living with relatives. After her death in 2001, a post-mortem found 49 injuries on her body including cuts probably made by a razor blade and cigarette burns. Professional learning:

  • This case was the catalyst for the introduction of section 4 offence in the Domestic Violence Crimes and Victims Act 2005 of “causing or allowing the death of a child or vulnerable adult”.

2004 Margaret Panting (Sheffield)

Long Care Inquiry (Buckinghamshire)

Buckinghamshire County Council report on case of two homes for people with learning disabilities. For 10 years  Gordon Rowe a former social worker beat, tormented, drugged, neglected, indecently assaulted and raped many of the adults with learning difficulties who lived in the homes. The independent Inquiry examined why it took 10 years for the abusive regime to be exposed.  Failings were identified in a wide range of agencies which should have been able to detect and respond to the abuse.  The police investigation highlighted that many of the 26 local authorities with clients at the homes had had little or no contact with them for years and some were not even aware they had clients at the home.  Despite the NHS paying the bills for the care of one resident, nobody visited her to check on her welfare for over 10 years.

Professional learning:

  • Families of residents should be taught how to spot signs of possible abuse
  • Residents placed out of area should be visited and reviewed on a regular basis.
  • Staff, professionals and relatives must be encouraged to speak out about concerns and made aware how to do so. The importance of whistleblowing procedures.
  • Abuse awareness training should be available to all professionals and the professional duty to report concerns highlighted.
  • Prompt and thorough investigations of allegations
  • Police require abuse and disability awareness training
  • Regulators should balance the information gained during inspections to improve reliability.

1998 Independent Longcare Inquiry (Buckingham)