Mr J was a fifty-nine year old vulnerable adult living in supported temporary housing after a period of homelessness following the breakdown of his marriage. In May 2008 he saw his GP and reported that his memory had deteriorated dramatically and that he used to have an alcohol problem. He was referred to mental health services where it was found that he had Alzheimer’s disease. Mr J was treated with medication and monitored. It emerged during 2008 that Mr J was experiencing difficulties with other residents at the supported housing and their associates. These people were variously said to be prostitutes and drug users. There were reports of thefts from Mr J which were investigated by police. Mr J would not agree to criminal charges being brought. It was judged that Mr J was able to live more independently and he moved on from the temporary accommodation he was in and he moved to alternative accommodation. In early 2009 police became aware of concerns he was still being exploited by acquaintances he had met at his previous accommodation. Police were involved in criminal investigations when Mr J made allegations against these people but he subsequently withdrew the allegations or they could not be substantiated. He was seen twice in the Accident & Emergency Department with facial injuries, which he insisted had been caused accidentally. Mr J was subject to a safeguarding referral which resulted in him moving to a care home on a temporary basis as a place of safety. After a short period, Mr J moved back to his own home. Monitoring visits found Mr J not be coping well. There were indications of excessive drinking, disorientation and inability to manage personal care needs. Two weeks after returning home, Mr J was taken to hospital where he was found to have multiple cuts, bruises and possible pressure sores of varying ages, and to be extremely dehydrated. He had multiple injuries to his brain. He deteriorated further and died in hospital four days later.
- The importance of relationship building with difficult to engage people or those at risk of exploitation.
- The importance of addressing isolation and supporting service users to strengthen or re-establish family/social networks as a means of protecting from further harm/exploitation.
- The importance of involving the GP and also having a GP when leaving residential care.
- There was no process of care planning, assessment and review.
- Input from professionals lacked direction and purpose, and was not alert to the safeguarding dimension of the situation.
- The need for clear and robust risk management and understanding as to the threshold for referring issues into the safeguarding procedures.
- There was a confused approach to the implementation of safeguarding arrangements once it became clear that Mr J was being exploited and abused. There was a lack of compliance across agencies with basic safeguarding procedures relating to the notification, recording and follow up of safeguarding concerns.
2013 June Serious Case Review regarding Mr J (Kent)
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.
- 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)
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’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.
- 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)