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Learning from Safeguarding Adults Reviews – SAR ‘Ella’


The Torbay and Devon Safeguarding Adults Partnership would like to thank the Devon Care Homes Collaborative for their contribution in co-producing this provider briefing to raise awareness of financial abuse.


Ella was a 77-year-old woman murdered in her home in January 2021 by an employee working for a domiciliary care provider. The murder followed an allegation of financial abuse and fraud committed by the employee against Ella.

On 31st December – Ella noticed that there should have been almost £3000 more in the account than there was. On 8th January – it was found there had been transactions unauthorised by her.

The individual was found guilty of murder on 30 July 2021 and was sentenced to life imprisonment. A Safeguarding Adults Review (SAR) was undertaken by the Safeguarding Adults Partnership. An inquest into Ella’s death was also completed in October 2021.

Services commissioned

Devon County Council (Integrated Adult Social Care) commissioned care from 13th April 2020 with a Provider who provides 24-hour care, to people in their own homes. The Provider had been twice inspected by the Care Quality Commission and rated as ‘good’. People being supported by staff described them as caring, compassionate, and demonstrated good awareness of each person’s safety. A voluntary organisation had also been in touch with Ella for several years.


Ella’s health difficulties were many and severe. She insisted the back door to her house was unlocked. She was deemed to have ‘capacity’ and was independent in managing her finances.  She had previously lent money to a previous dog walker. She was an adult at risk.

The Carer

The employee was employed by the Provider from 26 April 2018 until 15 January 2021 and (unfortunately) became Ella’s sole carer. He had no prior experience in a caring role.


A second character reference mentioned a previous caution by the police. His DBS showed a number of criminal offences between 2003 and 2007 including destroying property, drunk and disorderly behaviour and Actual Bodily Harm. The DBS certificate recorded cautions related to two offences of possession of drugs, cocaine on 1 August 2017 and cannabis on 12 August 2017.

Non DBS disclosures

There was a police record of possession of class B drugs which was not noted on the DBS certificate. There was also no record of domestic abuse call-outs on the certificate, although police attended domestic incidents/arguments. Information provided by Devon and Cornwall Police to the review indicated there were seven domestic abuse callouts to the employee and a previous partner, and he was subject to a penalty notice for disorder and possession of drugs.  This information was not disclosed on the DBS.

Devon and Cornwall Police explain that Domestic Violence information was not considered for disclosure. In the DBS disclosure for the employee, qualifying guidance was not taken into consideration therefore providers, may risk placing undue reliance upon DBS information which could be incomplete and deploy staff with some history.

Additional information may have enabled the provider to make a more comprehensive assessment of the potential risk the employee may have posed as a care worker.

Previous concerns

In 2019, a safeguarding referral was raised by the ambulance service, however, a decision was taken there was insufficient information to progress a safeguarding referral.


The Provider did not take any specific steps to assure itself that the employee was not continuing to take drugs. The employee had begun a relationship with the sister of the Registered Manager, who was also a Director of the company. She had provided the personal/character reference for him. The reference did not mention the volatile nature of his relationship with his wife.

The Torbay and Devon Safeguarding Adults Partnership wants Care Providers to be briefed about this SAR with particular focus on:

  • preventing financial abuse
  • limitations of DBS disclosures
  • understanding and interpretation of DBS disclosures
  • exercising ‘professional curiosity’ when monitoring the performance of staff
  • being vigilant when a client is predominantly in the company of a single care worker
  • Providers must not rely upon references from referees with a strong personal relationship with the applicant.


Curiosity – A greater exercise of curiosity may have revealed that the carer was going beyond his brief and nurturing an exploitative relationship with Ella.

Vigilance – Given the often-hidden nature of financial abuse providers should be aware of the need to exercise greater vigilance. The practice of having a team around a person, as opposed to a single carer, is important for continuity of care and also protection of the cared for person.

References – Providers should exercise caution regarding references from referees where there is potentially a strong personal relationship with the applicant. More independent references, including those from previous employers, should always be requested.

DBS limitations – Not all relevant information was disclosed under the DBS certificate. As part of the learning from this SAR, all partner agencies have been reminded of the importance to share additional information they may have that may not be contained within a DBS disclosure. This will support a more robust risk assessment and informed consideration of the potential risk posed by the employee.

Care and Support provision – Clients who are isolated and lonely may be at greater risk of being exploited. Care and support plans should consider a client’s vulnerability and the potential risk of financial abuse.

Safeguarding – A previous concern raised regarding potential financial abuse should have resulted in partner agencies exercising professional curiosity and asking more questions.


The Care Quality Commission Regulation 19 Fit and proper persons employed, sets out the requirement of providers to ensure robust recruitment processes, including relevant checks and the requirement for ongoing monitoring of staff.

Regulation 19: Fit and proper persons employed – Care Quality Commission (

Health and Social Care Act Regulations 2014 require:

1.     Proof of identity including a recent photograph.

2.     A criminal record certificate.  CQC expects each provider to undertake the level of DBS check for which a particular staff member is required.

3.     Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced criminal record certificate issued under section 113B of that Act together with, where applicable, suitability information relating to children or vulnerable adults.

4.     Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to: (a) health or social care, or (b) children or vulnerable adults.

5.     Where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why the person’s employment in that position ended

6.     In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed.

7.     A full employment history, together with a satisfactory written explanation of any gaps in employment.

8.     Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.

Skills for Care have tools available from their website to support employers recruit and retain a suitable and safe workforce. An example is this Safe and Fair recruitment guide that provides guidance for providers on employing people with convictions, and also provides very helpful Safe Recruitment checklists.

Safe and fair recruitment (


You can access the full SAR Ella report here and the SAR Ella Executive Summary here

More information regarding Safeguarding Adults Reviews can be viewed here

For more information on the Torbay and Devon Safeguarding Adults Partnership, its Partners and its work click here