Skip to content

SAR Ella: Executive summary

Background to the review

Ella was a 77 year old woman who was murdered in her home between 9 and 12 January 2021 by Mr. M, an employee of Complete Quality Care Ltd, an independent care provider.

The murder followed an allegation of financial abuse and fraud committed by Mr. M against Ella while he was her care worker. He had used her bank card to steal cash while undertaking shopping for her. When this was discovered he was suspended by Complete Quality Care but returned to her home on two occasions, on the second of which he committed the murder.

Mr. M was found guilty after a trial and on 30 July 2021 was sentenced to life imprisonment with a minimum tariff of 30 years.

Agencies involved with Ella

The following organisations were involved with Ella and contributed information to the review:

  • Northern Devon Healthcare NHS Trust.
  • Devon County Council Adult Social Care.
  • General Practitioner, Bideford Medical Centre.
  • Devon and Cornwall Police.
  • South Western Ambulance Service NHS Foundation Trust.
  • Complete Quality Care Ltd.
  • TorrAGE Ageing Well.


Ella lived alone and did not have many contacts with her family. Her health difficulties became increasingly severe during 2019-20. She suffered from osteoarthritis and osteoporosis, degenerative disc disease in her lumbar spine, historical alcohol dependence and recurrent depression. Her mobility decreased and in later months she slept downstairs. She was admitted to hospital on several occasions, often because of falls.

She became more dependent upon carers for daily personal care and throughout this period for shopping. She had a regular dog walker to exercise her two greyhounds.

In April 2020 a service was commissioned by Devon Cares on behalf of Devon County Council to provide support to Ella. Complete Quality Care Ltd were contracted initially to attend seven days per week, three times per day. The care plan was amended seven times to take account of Ella’s changing needs and also maintain her compliance. The final plan was completed on 22 October 2020 and reduced the number of carers to one.

The role of carers was to assist with personal care, prompt medication, support with nutritional requirements and home environment, and ensure the dogs were fed.

The provider was also advised about Ella’s previous experience of domestic abuse at the hands of her second husband.

Mr M

Mr. M. was employed by Complete Quality Care Ltd from 26 April 2018 until 15 January 2021. For most of the time, this was as a relief worker, but he took on more hours when he became Ella’s sole care worker in October 2020. He had no previous employment experience as a care worker.

He was convicted of a number of criminal offences between 2003 and 2007, including destroying property, drunk and disorderly and Actual Bodily Harm (ABH). These occurred from the ages of 18 to 22 years.

In 2014 Mr. M. was awarded a penalty notice for disorder and possession of class B drugs. In addition, on 7 January 2018, he was cautioned for two offences of possession of drugs – cocaine and cannabis.

Police officers were called to attend domestic incidents or arguments between Mr. M and his wife on seven occasions between 2014 and 2017. Both parties reported that they had been assaulted by the other on occasion, but no formal action resulted.

Mr. M. was 35 years old at the time of the murder.

Assessment and management of the risks faced by Ella

In respect of Ella’s many health difficulties there was a high level of inter-agency cooperation and information sharing. There was a frequent concern that her own actions would put herself at risk, especially during the period in June 2020 when she was refusing help.

The care and support plans do not reference a risk of financial abuse. An allegation made by Ella on 13 January 2020 about theft by a previous care worker was not raised as a safeguarding concern. Sharing this detail would have added to a more complete assessment of Ella’s vulnerability and could therefore have been included in the care and support plans and information to providers.

Ella underestimated the potential risks to her personal safety. Staff report that they frequently raised this issue with her. Although she had a keysafe for the front door of her house, the back door could not be effectively secured. She also liked to keep it open for her dogs to go into the garden. This was the route by which Mr. M. entered the house on the day of the murder.

Assessment of Ella's mental capacity to manage her financial affairs

There appears to have been no formal assessment of Ella’s mental capacity, including in relation to her financial affairs, but she was assessed informally each time she was admitted to hospital and deemed regularly to have mental capacity.

She was however generous and trusting with her money and appears to have offered to help Mr. M. financially. While technically competent to manage her financial affairs, she sometimes placed herself at risk of abuse through her trust in others.

Communication and information sharing between agencies and with the independent provider

Information was made available to the provider by the Police through the DBS process. The purpose of providing information through the DBS process is to assist employers to make informed assessments of risk. The DBS certificate recorded Mr. M.’s convictions and cautions for possession of drugs but not the penalty notice for disorder and possession nor the domestic abuse callouts.

Devon and Cornwall Police followed the Home Office Statutory Disclosure Guidance. The decision not to disclose the domestic abuse callouts was because

  • there had not been ‘significant violence’
  • the domestic violence had not been committed against a vulnerable person
  • the activity relating to the DBS check was not in the individual’s own home

A separate section of the guidance does allow officers to consider whether the information is relevant to considerations of risk that the individual may pose to vulnerable adults and whether there is a reasonable relevance to the workforce connected with the employment/regulated activity sought.

It would appear that this qualifying guidance was not taken into consideration in determining the relevance of the callout information. Disclosure of the penalty notice (defined as a criminal justice outcome) would also have been relevant information in building a picture of the extent and frequency of Mr. M’s drug taking and examples of disorderly conduct.

It is concluded therefore that there was further information held by the Police that would have allowed the provider to make a more comprehensive assessment of the risk Mr, M. may have posed as a care worker.

Recruitment, training and supervision of Mr. M by Complete Quality Care and his suitability to be employed as a care worker

The relevance of the cautions was not presented accurately in the subsequent risk assessment prepared by Complete Quality Care when Mr. M. was appointed. The organisation did amend its alcohol and drugs policy to allow for drug testing of employees. However it did not set up an arrangement with a contractor to enable testing to take place in a timely way. In the event Mr. M. was never tested.

Although a reference was received from his previous employer, a character reference was provided by the sister of the Registered Manager who began a personal relationship with him two months later and remained his partner until he was convicted of the murder.

The work undertaken by the police following the murder investigation indicated that Mr. M. was involved in the buying, selling and using of drugs in the period right up the time of the offence. His partner it would appear was aware of this. According to the Registered Manager she at no point reported any information about his drug taking other than the two cautions which pre-dated his employment.

Three weeks before the murder the provider’s coordinator undertook a planned home visit to Ella with Mr. M. present. She commented very positively on the rapport they enjoyed. There was no discussion about any tasks being undertaken by him that may have involved him using her debit card. As he was a sole worker with Ella, a visit alone with her and a greater exercise of professional curiosity may have revealed that Mr. M. was going beyond his brief and raised suspicion.

1st Learning point

Given the often-hidden nature of financial abuse providers generally should be aware of the need to exercise greater vigilance, especially when supporting clients with limited independence and/or capacity. The practice of having a team around the individual, as opposed to a single carer, is valuable both for continuity of care and for protection of the service user.

Taking account of all the information held by the police relating to the period between 2014 and 2018, it is hard to conclude that Mr. M. was suitable to be recruited as a carer working alone with vulnerable adults.

Although Complete Quality Care had only partial information concerning his drug misuse initially, the organisation did not take sufficient steps to assure itself that this behaviour was not an ongoing risk to its clients.

The subsequent information revealed during the murder investigation indicates that he could have been dismissed from his post in accordance with the company’s alcohol and drug policy well before he was introduced to Ella had this information been made known to the provider or other professionals.

Equality and diversity considerations

Early on in her care and treatment, Ella requested that she only had female carers for personal care tasks, partly because of her experience of domestic abuse. Mr. M. was introduced when she was being attended by two carers. It appears that she then requested that he continue when the care package was reduced to one care worker. She began to form a more personal relationship with him, describing him at one point as like a grandson.

Where there any missed opportunities to identify and prevent the financial abuse and subsequent murder?

Ella was considered a vulnerable victim by the police and could have been graded for a visit within 24 hours. It was decided that this was not necessary because there was a named suspect, no immediate safeguarding risks were disclosed and the suspected member of staff had been suspended with immediate effect.

The police were not informed after the first occasion when Mr. M visited Ella despite being suspended and instructed by the provider not to contact clients. If this had been known, it is likely that the risk assessment would have been raised to a higher level. This may have prompted an earlier contact with her and/or Mr. M. However, it is impossible to determine whether this would have deterred Mr. M, from returning to the house, especially as he visited Ella again within 36 hours.

Good practice

Ella received a higher-than-average number of home visits from Community Matrons in spite of the commencement of the COVID-19 pandemic during the period examined. Every effort appears to have been made to engage with her and to overcome the resistance she often showed towards professionals.

The TorrAGE Manager appears to have established a rapport with Ella and took responsibility to liaise with her bank to establish that there were thefts being made from her account.

All agencies moved quickly to inform the police when Mr. M. was suspected of financial abuse and Complete Quality Care immediately suspended him from duty.

2nd Learning point

Although in this instance Mr. M. would have already known the specific reasons for his suspension as he was present when the loss of money was confirmed by Ella and the TorrAGE manager, the details of the allegation should not normally be disclosed to a staff member at this stage. Following the decision to suspend, providers should immediately consult with Safeguarding and/or the police about next steps.


It is recommended that:

Care providers are briefed about the content of the SAR with a particular focus on:

  • preventing financial abuse
  • understanding and interpretation of DBS disclosures
  • exercising ‘professional curiosity’ when monitoring the performance of their staff and assessing the quality of care being delivered to service users
  • being vigilant when a service user is predominantly in the company of a single care worker

Torbay and Devon Safeguarding Adults Partnership use the findings of the SAR as an opportunity to remind adult social care providers about safe recruitment practices and provide guidance about employing staff who have criminal convictions to work with vulnerable people. This should include necessary risk assessments and monitoring or supervision arrangements.

The Care Quality Commission is advised of the findings of the review and undertake an audit of risk assessments where care staff have had a positive DBS disclosure to gain assurance that appropriate measures have been put in place to mitigate risk.

Complete Quality Care Ltd and care providers generally must not rely upon references from referees with a strong personal relationship with the applicant. In these circumstances another more independent reference, in addition to that from a previous employer, should also be requested.

If Complete Quality Care Ltd and care providers generally recruit a staff member with a positive DBS disclosure, they should include in the risk assessment a clear plan as to how their future behaviour will be monitored to ensure that any risk to clients can be mitigated.

Devon and Cornwall Police review the application of the Quality Assurance Framework in respect of DBS checks requested by domiciliary carers to ensure that Chief Officer Delegates are aware of the environment in which an individual will be working and the need to apply the guidance in section MP7a of the QAF to their decision-making.

Torbay and Devon Safeguarding Adults Partnership advise the Home Office of gaps in the DBS system or interpretation of the QAF that have come to light as a result of this review.

Devon County Council Commissioning work with Devon and Cornwall Police to determine how to ensure care staff of independent providers with any previous history of perpetrating domestic abuse are not placed with service users who have experienced domestic abuse in past relationships.

Torbay and Devon Safeguarding Adults Partnership use the findings of the SAR as an opportunity to raise awareness of financial abuse across all staff groups and reinforce the importance of recording all safeguarding incidents to build a comprehensive profile of the risks to which a service user may be exposed.