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SAR: Ella

1. Background to the report

1.1      Ella was a 77-year-old woman who was murdered in her home between the 9th and 12th January 2021 by Mr.M., an employee of Complete Quality Care Ltd, an independent care provider. She had a number of health and mobility difficulties that severely restricted her lifestyle and rendered her in need of care and support.

1.2      The murder followed an allegation of financial abuse and fraud committed by Mr. M against Ella. He was suspended by Complete Quality Care but returned to her home where he committed the murder.

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

1.4      A Safeguarding Adults Board (SAB) is required to undertake a Safeguarding Adults Review (SAR) where:

  • an adult with care and support needs has died and the SAB knows or suspects that the death resulted from abuse or neglect
  • there is reasonable cause for concern about how the SAB, its members or others worked together to safeguard the adult

1.5      The inquest into Ella’s death was completed on 22 October 2021. There are no other reviews taking place into the circumstances of her death.

2. Scope and key questions to be addressed

2.1      In the light of information provided in organisations’ Individual Management Reviews (IMR) the following issues were identified.

  • Was there a critical path that led to the abuse and murder of Ella?
  • Were there any missed opportunities to identify and prevent the financial abuse and subsequent murder?
  • Was Ella’s level of vulnerability to abuse accurately assessed and appropriate risk management measures put in place?
  • Was there sufficient communication and information sharing between agencies and with the independent provider, especially in relation to Ella’s vulnerability and any safeguarding concerns?
  • Had an assessment been undertaken in respect of Ella’s mental capacity to manage her financial affairs?
  • Were the recruitment, training and supervision of Mr. M. by Complete Quality Care undertaken to a sufficient standard?
  • Was there any information, known or unknown at the time, that indicated he was not suitable to be employed as a care worker?
  • Do the agencies and the provider have up to date policies in relation to preventing financial abuse?
  • Were there any equality and diversity considerations in relation to Ella and, if so, how were they handled?

2.2      The review also takes account of any relevant learning from local or national reviews concerning financial abuse and abuse by paid carers.

2.3      The analysis of events begins in March 2019 when a safeguarding concern was raised by South Western Ambulance Service Foundation Trust after being called out to Ella’s home. There is a more detailed section covering the period between 31 December 2020 when the financial abuse was first discovered by Ella and the 11 January 2021 when her body was found.

3. Organisations involved with Ella

The following organisations have contributed information to the review either in written form or through verbal communication with the Lead Reviewer.

3.1      Northern Devon Healthcare NHS Trust

The Trust had substantial contact with Ella over a number of years and particularly in the period covered by this review. It has submitted an Individual Management Review (IMR) and chronology dating from 17/06/2019.

3.2      Devon County Council Adult Social Care

Devon County Council commissioned Complete Quality Care via its contract with Devon Cares, a trading name of Devon Healthcare NHS Trust, to support Ella from 13 April 2020. Adult Social Care has provided the Internal Incident Report prepared, which covers the period from 23 September 2020 until her death. It has also shared the minutes of four whole service safeguarding enquiry meetings, convened under the multi-agency safeguarding procedures, to review the concerns triggered by the police investigation into her murder. These took place between 21 January 2021 and 12 May 2021.

3.3      General Practitioner, Bideford Medical Centre

3.3.1   The GP practice provided an IMR covering the period from 9 March 2019. Ella had been a patient at the practice for decades. She was seen by a number of GPs at the practice during the period reviewed.

3.4      Devon and Cornwall Police

3.4.1   Devon and Cornwall Police made the initial referral for the case to be considered as a Safeguarding Adults Review. The force produced an IMR referencing one previous call-out prior to the notification of alleged financial abuse and the subsequent investigation into her murder.

3.5      South Western Ambulance Service NHS Foundation Trust

3.5.1   No information has been provided by South Western Ambulance Service, although it is known from other agency records that they made safeguarding or health and welfare referrals in the period covered.

3.6      Complete Quality Care Ltd

3.6.1   Complete Quality Care [1] is an agency that provides 24-hour, all year care to people in their own homes in Bideford, Barnstaple and the surrounding areas of Devon. The organisation was commissioned to work with Ella as part of the ‘Living Well at Home’ contract, sub-let to Devon Cares by Devon County Council. Devon Cares was an arm of Northern Devon Healthcare Trust.

3.6.2   The organisation has twice been inspected by the Care Quality Commission and on each occasion was rated as ‘good’. The most recent inspection was published in March 2019. At the time of the inspection the service was supporting 63 adults. People being supported by staff described them as caring, compassionate and felt that they treated them with dignity and respect. Staff were considered to have the skills and knowledge necessary to meet people’s needs. The inspection report comments that staff demonstrated good awareness of each person’s safety and how to minimise risks for them. Quality monitoring systems included audits, observation of staff practice and contact with service users to check they were happy with the service provided.

3.6.3   Complete Quality Care completed an IMR and has responded to requests for further information from the Lead Reviewer.

3.7      TorrAGE

3.7.1   TorrAGE Ageing Well (part of TTVS a voluntary organisation based at Torrington Community Hospital), had been in touch with Ella at different times for several years. During the period of this review her shopping was undertaken on a weekly basis, usually by the project manager who was her support worker.

[1] To avoid confusion with the Care Quality Commission the title of Complete Quality Care is used in full or the organisation is termed ‘the provider’ from hereon in the report.

4. Contact with family members

4.1      Ella did not maintain regular contact with family members and on occasion told organisations that she had no next of kin. She did however have a daughter and a half sister.

Letters were sent to both parties to invite them to be informed about and contribute to the review. Her half-sister responded and has contributed her own perceptions and memories of Ella. She has read the final report and is satisfied that it is a comprehensive and accurate portrayal of her half-sister. However, her daughter has not taken up the offer of contact.

5. Ella

5.1      Little information is available about Ella’s family background. She was estranged from her daughter and told her GP that she had died. She told some agencies that she had no next of kin, although that was not true. Her daughter in fact was able to hear proceedings at the Crown Court and appears to have spoken to the press after the trial.

5.2      Her half-sister who lives in Kent was her closest relative. They had not seen each other for about two years and had phone conversations every few months when Ella was well enough to talk. Her half-sister explained that Ella was ‘a very proud person who didn’t ever think she was old and needed help. She would never trouble me with her problems while they were going on. She was generally erratic throughout her life and very independent.’

5.3      In fact Ella’s health difficulties became increasingly severe during 2019/20. Health records indicate that 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.

5.4      She therefore became more dependent upon carers, at some points for daily personal care and throughout this period for shopping, which was undertaken by TorrAGE. She had a regular dog walker to exercise her two greyhounds, which were very important to her. On occasions, dog faeces were found in the house when professionals visited. She insisted that the back door to her house was unlocked so that the dogs could go into the garden, although there was a dog flap in the door. This gave rise to concerns about her personal safety. It is also unclear whether this door could be locked or if it was secured during the weekend when her death occurred. There was a keysafe to the front entrance.

5.5      Notwithstanding her health difficulties she was very independent and strong-minded, described as someone who would not back down if challenged but also someone who lacked insight into some of her risky behaviours. In April 2020 Ella advised that she had been abused by her second husband and did not like males coming near her. She would however consider a male carer if he was helping with transfers only and not undertaking personal care. When Mr.M. was introduced into the care arrangements, they got on very well and it was later discovered that Ella was said to have promised him money to help him buy a car.

5.6      Ella’s mental capacity was not formally assessed. However, she was ‘deemed to have capacity’ on several occasions. One instance was in relation to whether she had capacity to refuse care during her admission to hospital in July 2020 (7.14). Although seen as an unwise decision, Ella was deemed to have capacity to cancel her care package. Much time was spent trying to persuade her not to do so and also to tailor the care package so that it would be acceptable to her. She appeared confused when the Police attended her home on 27 April 2019 and was admitted to hospital on one occasion with confusion (13 July 2020).

5.7      She is described as having dementia in the IMR from the Health Trust but there is no record to indicate that this was a formal diagnosis. At each admission to hospital mental capacity was considered and documented using the ‘Memory and cognition Assessment’. None of these assessments identified any reason to doubt her capacity and complete a formal Mental Capacity Assessment.

5.8      The Care Act assessment of April 2020 noted that no formal Mental Capacity Assessment was needed and that she was independent in managing her finances. She had capacity to understand her outgoings and income and write cheques for all her bills with her TorrAGE personal shopper, who felt that she knew exactly what was in her bank account. She first became aware of the thefts from her account from the receipt slip provided to her by the TorrAGE shopper after she had taken out money for her at a cashpoint as requested. The latter also described a situation where Ella indicated she had lent money to a previous dog walker, but never received the payment back. She would not divulge any details.

5.9      When she was due to complete a financial assessment in respect of the funding for her care, Complete Quality Care suggested that the assessment paperwork be sent to them so that they could help Ella fill it in as she ‘would probably throw it away’.

5.10    In April 2020 a service was commissioned by Devon Cares on behalf of Devon County Council to provide support to Ella. This was originally for 2 carers 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, ensure the dogs are fed.

5.11    The following risks were identified in the care plan:

  • Risk of self-neglect – Carers to visit daily to support Ella and reduce her risk of self-neglect.
  • Risk to skin integrity and risk of pressure damage – Carers to visit to support to apply cream to any pressure risk areas, to encourage to get out of bed and onto the commode on all visits. Community Nursing and carers to monitor skin integrity.
  • Risk of being unable to maintain personal hygiene and appearance – Carers to support with personal care, and toileting needs.
  • Risk of malnutrition and dehydration – Carers to encourage and support Ella with meals and drinks.
  • Risk of being unable to take her medication as prescribed – Carers to prompt and support Ella to take her medication due to her poor vision and arthritic hands.

5.12    Agencies were also advised about Ella’s previous experience of domestic abuse.  Her second husband had been physically abusive and controlling. She would accept male carers if they undertook transfers only and no personal care, and if they were with a female carer present.

6. Mr. M

6.1      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 carer.

6.2      He had no previous employment experience in a caring role. His immediate previous employment was refuse loading and street cleaner deliveries with Devon County Council. A reference from his supervisor who had known him for three years describes him as ‘honest and hard-working’.

6.3      A second character reference was from a senior carer at Complete Quality Care, the sister of the current Registered Manager. She had known him for six years. She also referred to his honesty but in addition mentioned a previous caution by the police. At the time of writing the reference she was a director of the company and a friend of Mr. M., although shortly afterwards they began a personal relationship which lasted until he was found guilty of the murder.

6.4      The provider staff file records a number of criminal offences between 2003 and 2007. The offences included destroying property, drunk and disorderly and Actual Bodily Harm (ABH). The sentences imposed for these offences included a compensation order, fines (twice) and a curfew with electronic monitoring. These occurred from the ages of 18 to 22 years.

6.5      In 2014 there is a police record of Mr. M. being awarded a penalty notice for disorder and possession of class B drugs (not noted on DBS certificate). In addition, on 7 Jaunary 2018 he was cautioned for possession of drugs. The DBS certificate records that these cautions related to two offences of possession of drugs, cocaine on 1 August 2017 and cannabis on 12 August 2017.

6.6      The police chronology records that officers were called to attend domestic incidents/arguments between Mr. M. and his wife on seven occasions between 2014 and 2017. In February 2014 Mr. M. was reported as having been the victim of an assault by his wife. In December 2017 his wife alleged that he had hit her across the face. She also alleged other previous assaults which had not been reported at the time. On this occasion, Mr. M’s wife did not want to pursue the complaint and he was neither arrested nor interviewed. He and his wife separated in January 2018. There is no record of the domestic abuse call-outs on the DBS certificate.

6.7      At the time of his appointment a risk assessment was completed by the provider’s Registered Manager. It references a ‘caution for class A and B drug – no police action taken and is an isolated incident.’ It does not state the date of the caution nor that there were two separate offences. The cautions were given three months before he began work for Complete Quality Care.

She summarised:

“After reviewing Mr. M.’s DBS, we have agreed that he is of no threat to any of our clients, the convictions raised were from when he was a teenager and finding his feet in life, His last conviction was in 2007. We have received reference on M.’s behalf claiming he has a good nature and is recommended for the role of support worker.

Mr. M. has received a warning from the police in regard to drug possession but no action was taken against him.” The entry continues that they had discussed at length with Mr. M. that there was a no tolerance to drug or alcohol policy in place, and that he understood that if they were concerned regarding his drug use the company would have no option but to terminate his contract of employment. “This has led to us as a company to adapting our drug and alcohol policy to allow us as a company to request staff participate in a drug or alcohol test if we are to be concerned of misuse.”

6.8      The company’s drug and alcohol policy states:


e) employees may be required to undergo testing for alcohol or drugs in their system in certain defined circumstances.”

The policy does not go on to set out what ‘defined circumstances’ may be.

In the event Mr. M. was not tested for drugs during his employment. The Registered Manager explains that this was because there had been no concerns raised that he had still been using drugs.

6.9      Mr. M. completed a range of training events online in 2019 and 2020, including in relation to safeguarding and mental capacity. On 18 September 2020 he received a welfare check/supervision from the Registered Manager. On 18 December 2020 the Care Coordinator undertook a spot check home visit to Ella whilst he was present. This is outlined in more detail in section 7.18.

6.10    According to the TorrAGE manager who met him on several occasions both with Ella and other clients they had in common, he was a jolly character, popular with clients. However, she also reported to Complete Quality Care that he was not fulfilling his duties to keep the house clean and in a hygienic condition.

6.11    When planned visits reduced and Mr. M. effectively became the single care worker, personal care remained one of the tasks in the care plan. The view of the provider is that this was in case personal care was necessary. Mr. M. would apply creams or dressings if required but that generally his role was to assist with domestic tasks. These were usually based around cleaning after Ella’s dogs and walking the dogs when the dog walker was not around, preparing basic meals and laundry, bins and dishes. The manager’s view was that Ella was not a service user who would be persuaded to engage in personal care or socialise if she did not want to. She was very firm with her choices.

6.11    At the time of Ella’s murder he was 35 years old.

7. Key events since March 2019

7.1      During 2019 and 2020 there was a considerable amount of inter-agency working with Ella, primarily because of her health and mobility issues. She was admitted to hospital on six occasions. She was regularly visited at home by Community Matrons. There were six occasions when safeguarding concerns were or could potentially have been raised.

7.2      9 March 2019, a safeguarding/welfare referral was raised by the ambulance service on account of self-neglect after she was found on the floor of her home. The crew were concerned about the state of her house and felt she was unable to cope at home.

The referral was discussed in the Safeguarding Hub and a decision taken that there was no information to warrant taking the referral forward under safeguarding procedures. The most proportionate response was considered to be to contact Ella to offer her a Social Care Assessment.

7.3      27 April 2019, police attended. Ella alleged that people were trying to break into the house but officers found no signs of disturbance. She appeared confused and was not security conscious. Officers made the property as secure as she would allow, but she stopped them locking the back door. Graded medium risk. No referrals made ‘as subject given adequate safeguarding advice by attending officers’.

7.4      17 – 21 June 2019, admitted to hospital for facture of the patella following a fall down 11 steps.

7.5      30 July – 1 August 2019, admitted to hospital on account of knee pain following a fall while mobilising with Zimmer frame.

7.6      16 November 2019, ambulance service attended but Ella refused admission to hospital and safeguarding referral.

7.7      13 January 2020, disclosure to Community Matron of allegation that a private care worker had stolen £500 from her Nationwide account. Ella indicated that she did not want the police to be involved and no safeguarding referral was made.

7.8      24 February – 2 March 2020, further hospital admission for fracture of femur after she fell in her bedroom.

7.9      2 April 2020, declined admission to care home or Rapid Intervention Team support. Was deemed to have mental capacity to decline.

7.10    3 June 2020, fall at home. House filthy with soiled duvets and chairs soaked in urine. Dog faeces everywhere. Refused admission to hospital, GP commented that she had capacity to do so.

7.11    4 June 2020, ‘urgent’ safeguarding referral by Ambulance Service in respect of spinal problems and recent fracture. The following day the Community Matron contacted Adult Social Care to discuss concerns that Ella was not coping and try to arrange continuing support from the provider. The care and support plan was revised in response to the issues raised by the Ambulance Service.

7.12    17 June – 18 June 2020, admitted to hospital following a collapse. Severe neck and head pain. Reference to amnesia. Neurological examination showed no neurological deficit.

7.13    19 June – 25 June 2020, following discharge from hospital Ella refused to allow entry to her home and was verbally abusive to the provider’s care workers. Community Matron was also denied access to change her pain relief patch.

7.14    10 July 2020, GP visited to assess confusion. Safeguarding referral from Ambulance Service as Ella was declining all help. Safeguarding Team advised but no action as Adult Social Care were already aware of issues and dealing with them.

7.15    13 July – 29 July 2020, admitted to hospital with confusion. She expressed unhappiness with and ‘persecutory ideas’ about her care workers during her stay in hospital. Psychiatric assessment on 23 July advised that there was no evidence of acute psychiatric problem and she was deemed to have capacity. Assessed as low risk of harm to self, to others and from others. It was felt that her personality was the cause of her behaviour.

7.16    31 July – 6 August 2020, admitted to hospital feeling physically unwell, increased heart rate and significant drop in blood pressure.

7.17    From this point until December 2020 Ella was supported by frequent visits by the Community Matron service. Her relationship with care workers from Complete Quality Care was variable. On one occasion she was rude to a carer and told her to get out of the house. The provider changed a care worker at Ella’s request because she felt she was too brusque when washing her. Her relationship with care workers appears to improve from October onwards.

7.18    Ella’s ambivalence about professional visitors and her care workers is evident at different points during this period. ‘She either took to you or she didn’t’. In June 2020 she had refused all care for a 10-day period and often cancelled visits. She was angry and aggressive towards her GP concerning her drug prescription in July just before the safeguarding referral when she was declining help. A locking medicine cabinet was later introduced in response to occasions when she overused prescribed drugs.

7.19    The provider’s Care Coordinator undertook a pre-arranged spot check on 18 December 2020. She described a good rapport between Mr. M. and Ella. There was lots of banter between them. Ella felt that he was more laid back with her than other care workers, went at her pace and let her make her own decisions. All areas were reported to be clean and tidy. There is no record of any discussion about money handling during the visit which the provider has indicated Mr. M. was not authorised to undertake.

8. 31 December 2020 until 11 January 2021

8.1      Thursday 31 December 2020

The TorrAGE manager was asked to obtain cash by Ella. On examining the receipt with the balance Ella noticed that there should have been almost £3000 more in the account than there was. Mr. M. arrived during this visit and stated that he did not realise that he had to provide receipts for shopping and other transactions as the provider did not have a policy[1]. It was not possible to ring the bank at this point as Ella’s phone had run out of battery.

8.2      Thursday 7 January 2021

Ella reported to the Associate Community Matron that her bank balance was less than it should have been. She was advised to ring her bank and cancel her card on that day due to the risk of more money going missing. The Community Matron later liaised with TorrAGE who were already helping Ella contact the bank for a statement so that they could see where and when the money was taken.

8.3      Friday 8 January

The Community Matron liaised with the Manager at TorrAGE who had phoned the bank on speaker phone so that Ella was party to the conversation.  The bank detailed the transactions from her account during the period of October and November.  It was clear to Ella that these transactions had not been authorised by her. The TorrAGE manager then informed the police (1.27 pm) and raised a safeguarding concern. The bank card was stopped and a new card with pin was to be sent. She also contacted the provider advising them that Ella had alleged the fraud was committed by Mr. M. and suggested they change the Keysafe number. In the event this did not happen

The police recorded the referral from the TorrAGE manager (described as a support worker in the record). The officer was advised that Ella is bed bound and extremely vulnerable due to health issues. The manager suggested that any correspondence is sent to her in the first instance as Ella struggles to answer her phone. In response to a question the TorrAGE manager advised that Ella does not require a visit from officers. She herself does not recollect this. Crime report was allocated to CID. Contact made with the TorrAGE support worker and arrangements put in place to progress the investigation and speak to Ella over the coming days.

After receiving the phone call from the TorrAGE manager the provider’s Registered Manager tried to contact Mr. M. by phone to stop him attending Ella that day. Unable to do so she visited his home and informed him of the detail of the allegation. She then suspended him with immediate effect and told him he was not to visit or have contact with their service users until the allegation was investigated. She reported the theft to the Police and also the safeguarding team.

Adult Social Care (ASC) Customer Service Advisor at Care Direct took the referral from the Registered Manager at Complete Quality Care and created a welfare concern form, apparently unable to identify Ella as a current client because of bad phone line. Form was sent to Care Direct Plus North Assessment and Review team in-tray.

The TorrAGE Manager contacted the Community Matron to advise that she had sent the crime number to the bank. Mr. M. was the only care worker going in to visit Ella and had the number to the medication box.

Liaison took place between Community Matron and the provider’s Manager. A senior care worker would be visiting to see if Ella would let her in. Discussion of medication available to her over the weekend.

Police notified Community Matron that Mr. M. is being investigated and that he had accused the support worker from TorrAge of taking the money. The Community Matron agreed to be independent responsible adult to support Ella during the investigation process.

The Community Matron contacted the GP to let him know that Ella was in a very vulnerable position at the moment; that a safeguarding concern had been raised, and that she has a history of being abused. She advised key safe number was being changed. There was a risk that if Ella now turned away care workers due to loss of trust she would self-neglect or not cope like she did before. According to the GP practice IMR the call was for information and no action was requested or required from the GP.

Later that day Mr. M. visited Ella at home to tell her he had not stolen the money but that it was upstairs.

8.4      Saturday 9 January

Complete Quality Care replacement carer rang to say that she was concerned that Ella was trying to go upstairs to look for the missing money.

Police investigating officer tried to contact Ella.

ASC welfare concern form was forwarded to Safeguarding Adult Team hub as an allegation of abuse.

8.5      Sunday 10 January

Registered Manager and Care Coordinator of the provider made a home visit to try to find the money with Ella. They could not do so. Replacement care workers were visiting over the weekend.

8.6      Monday 11 January

The Safeguarding hub received a phone call from the provider’s Registered Manager reporting the allegation of theft and advising that Mr. M. had been suspended. There was discussion about the circumstances of the theft and his denial. Further discussion of Mr. M. visiting Ella at 5 a.m. in the morning. Ella indicated that she had not been concerned by such an early visit. (It was later confirmed that this visit took place on Friday evening.)

The Registered Manager also advised that Ella had alleged theft before by a care worker who was now employed by Complete Quality Care.

Later that morning Ella was found dead at her home by the provider’s carer who rang Mr. M. to inform him of this as she was not aware that he had been suspended.

[1] Complete Quality Care point out that a policy for handling service users’ money was in place and that Mr. M. had followed this procedure with other clients for whom he was authorised to buy shopping.

9. Analysis and findings

9.1      Was Ella’s level of vulnerability to abuse accurately assessed and appropriate risk management measures put in place?

9.1.1   Health and self-neglect

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 risk of self-neglect is referenced in all the care and support plans. This led to the provider being commissioned to support her and several changes to the care and support plan to take account of her wishes to reduce the amount of care being provided.

The care and support plans also reference, as information for providers, Ella’s previous experience of an abusive marital relationship.

9.1.2   Financial abuse

The care and support plans do not reference a risk of financial abuse. The police IMR refers to an allegation of theft by a care worker in 2012. Ella was also trusting with her money and, on the occasion mentioned by the TorrAGE manager in para 5.8, apparently had that trust abused.

The allegation made by Ella on 13 January 2020 about theft by a care worker was not raised as a safeguarding concern.[1]

On many occasions, professionals worked successfully to maintain the spirit of Making Safeguarding Personal and respect Ella’s wishes. Staff frequently are called upon to exercise judgment about whether to override an individual’s views either in their own best interests or for wider safeguarding reasons. On this occasion, it is recognised that a safeguarding referral should have been made.

It is clear that information about potentially dishonest carers should be recorded and passed to the Police as they may move between employers and also work as agency staff. However, it is also relevant in this instance because recording and 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.

9.1.3   Personal safety

Ella underestimated the potential risks to her personal safety. She had a keysafe for the front door of her house. The number on the keysafe should have been changed by the provider when the allegation of theft by Mr. M, was first made. This was not done. However, even if it had been changed, the back door could not be effectively secured. This was known by the agencies visiting her but not to the police when the thefts were reported. This appears to have been the way into the property that Mr. M. took.

Ella’s sister questions whether one of the agencies could have taken responsibility to arrange for/persuade Ella that it should be repaired.

However, even if it had been made secure, there is no guarantee that Ella would have locked it. During the call-out by the police in 2019 officers commented that she was not security conscious. There was also a dilemma for staff to resolve because of her concern for her dogs to have access to the garden. If the dogs were not allowed out, there were often instances of faeces being left in the house.

Health Trust staff and the TorrAGE manager report that they frequently raised the point about her personal safety with Ella.

9.2.     Was there sufficient communication and information sharing between agencies and with the independent provider, especially in relation to Ella’s vulnerability and any safeguarding concerns?

9.2.1   The Registered Manager of the provider confirms that she felt well supported by staff at Devon Cares. All care and support plans were received and she was aware of the fact that Ella had been previously subject to domestic abuse. However, after the murder she states that she was also made aware of a number of safeguarding issues that had previously been reported.

These issues were referenced in the SAR referral form submitted by the police. One occasion is the alleged theft by a private carer in 2012. A second reference is to a dispute in 2014 between Ella and a friend of a taxi driver whom she had taken in. He was refusing to leave and she alleged that he had also stolen money from her. The police attended twice and ensured that he had left the premises. It is not clear what was the outcome in 2012 nor if the police notified any other agency on either occasion of the incidents. Both pre-date the implementation of the Care Act and have not been investigated further. They do however reinforce the importance of a comprehensive risk profile of a service user being prepared and shared with providers.

9.2.2   Information made available to the provider by the police through the DBS process

The information provided by the Police to this review indicates that there were seven domestic abuse callouts to Mr. M. and his wife between 2014 and 2017. In addition, Mr. M. was subject to a penalty notice for disorder and possession of drugs in 2014. None of this information was disclosed to the provider on the DBS certificate.

9.2.3   The purpose of providing information through the DBS process is to assist employers to make informed assessments of risk. The responsibilities of the Police are governed by the Home Office Statutory Disclosure Guidance. This guidance sits alongside the Quality Assurance Framework (QAF)[2] which is a set of processes and more detailed guidance covering disclosure under the Police Act 1997.

9.2.4   Devon and Cornwall Police explain the reasons for not disclosing the domestic abuse as follows: –

“Domestic abuse is only considered ‘relevant for consideration’ in DBS terms if there was significant violence used against a vulnerable person and if the role being applied for is a role which would be carried out in the applicant’s home. Having reviewed the DV history it would appear that both Mr. M. and his now ex-partner were perceived victims over the years, no significant violence was recorded and neither are recorded as being vulnerable therefore the Domestic Violence information was not considered for disclosure.

All relevant areas of the Quality Assurance Framework (QAF) for DBS were followed in this instance. The information was not considered relevant under QAF and there was no indication of any transferable risk.

As per answers provided above the information was not considered relevant to the considerations of risk as were low level DV and the application was not for a home-based role. There was no indication of any transferable risk, therefore, would not be considered by the Chief Officer Delegate.”

9.2.5   In this account three criteria are set out to explain why there were restrictions on the information that could have been included in the DBS certificate in respect of Mr. M.

  • The term ‘significant violence’ is to some degree subjective and open to interpretation. However, the term does not allow for recognition of other forms of domestic abuse nor the frequency of events involving violence or abuse. In respect of Mr. M. the call outs on more than one occasion related to arguments with his wife in public, sometimes drunken. One allegation of violence was not taken forward.
  • That the domestic violence should have been committed against a vulnerable person. This appears to assume that violence against someone who is not vulnerable would not be transferrable to a setting where a potential victim is vulnerable. This in the experience of the reviewer is not a reliable assumption.
  • That the activity relating to the DBS check should be in the individual’s own home is not relevant to the circumstances of providers employing staff to care for vulnerable adults in their own home, often working alone.

9.2.6   Section MP7a of the QAF sets out a flow chart to assist officers in considering whether relevant information should be disclosed. The flow chart questions “Is it reasonable to believe that the information is relevant to considerations of risk that this individual may pose to children, vulnerable adults or both for this specific application?”

The guidance goes on the indicate that “all risk-relevant details and factors should be considered for disclosure. The information or behaviour must have a reasonable relevance to the workforce(s) connected with the employment or regulated activity sought and any risk should not be a fanciful one. Where applicable include reference to the level of access or supervision and the opportunity to put others at risk – relevant contextual information” (page 3)

9.2.7   In respect of the DBS disclosure for Mr. M. it would appear that this qualifying guidance was not taken into consideration in determining the relevance of the callout information. It is of concern therefore that providers, not being aware of these issues, may place undue reliance upon DBS information which could be incomplete and, as in this case, deploy staff with some history of being responsible for domestic abuse with service users who have previously been victims.

9.2.8   In relation to the information concerning the penalty notice, such a notice is described as a criminal justice outcome. Like a caution, it can only be issued with the individual’s consent, i.e. acceptance that the behaviour occurred. The police again have discretion not to include this in the DBS certificate if, for example, there was a passage of time since the relevant events occurred and the individual had since not come to the police’s attention. The police have not provided an explanation as to why the penalty notice was not included in the DBS certificate.

There were two subsequent cautions for possession of drugs three years later. In these circumstances disclosure of the penalty notice would have been relevant information in building a picture of the extent and frequency of both drug taking and also disorderly conduct on Mr. M.’s part, such as that revealed in the domestic abuse call outs.

9.2.9   It is concluded 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.

9.3      Had an assessment been undertaken in respect of Mrs. Ella’s mental capacity to manage her financial affairs?

9.3.1   There appears to have been no formal assessment of Ella’s mental capacity including in relation to her financial affairs. An assessment was undertaken in hospital in respect of whether she had capacity to decline care, although I have not seen any documentation in respect of this. She was assessed informally each time she was admitted to hospital and deemed regularly to have mental capacity.

9.3.2   There were occasions when she was considered to be confused (5.6). At one point she had an infection which may have contributed to this perception of her. There is a reference to dementia but this was never a formal diagnosis.

9.3.3   The information from the TorrAGE Manager, who had most contact with her over her financial affairs, is that she had understanding to sign cheques and was aware of what was or should have been in her bank account. She was however generous and trusting with her money. She also appears to have offered to help Mr. M. financially. Thus, while technically competent to manage her financial affairs, she sometimes placed herself at risk of abuse through her trust in others.

It is significant that the abuse occurred during the early months of covid-19 when debit cards were being used much more instead of cash, generally increasing the risk of fraud. It would have been easier for Mr. M. to have asked to use Ella’s debit card even if he was only shopping for some small items.

9.4      Were the recruitment, training and supervision of Mr. M. by Complete Quality Care undertaken to a sufficient standard?

Was there any information, known or unknown at the time, that indicated he was not suitable to be employed as a care worker?

9.4.1   In a previous section there has been discussion about the extent of information made available to the provider. This section focuses on how the provider used the information they did receive.

9.4.2   The DBS certificate provided at the point of recruitment of Mr.M. outlines that he had been cautioned for two separate instances of possession of drugs three months before he took up post. The events themselves dated from August the previous year. The status of a caution was not presented accurately in the subsequent risk assessment prepared by Complete Quality Care. Whilst a caution is of less seriousness than a conviction, it is still an admission of guilt and should not be regarded lightly. The risk assessment states, ‘No Police action taken and is an isolated incident’. ‘Caution which was put down to an isolated event, not serious enough to convict’. There were in fact two instances of possession which should have been regarded as an indication of a potential drug misuse risk on his part, especially the reference to a Class A drug cocaine. Mr. M. himself explained to the provider that this drug taking related to a period when he was under stress due to the breakdown in his marriage.

(The fact that he had been issued with the penalty notice for disorder and possession of drugs in 2014 which was not referenced in the certificate would have questioned whether his drug taking was an isolated event.)

9.4.3   As a result of recruiting Mr. M. Complete Quality Care amended its alcohol and drugs policy to allow for drug testing of employees. It has 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. In spite of the proximity of the cautions to him beginning work with the provider, the organisation did not take any specific steps to assure itself that he was not continuing to take drugs at that time, for example drug testing during the probationary period. The latter period was however extended on account of lateness, medication recording and the need for a moving and handling assessment.

9.4.4   At the time that the risk assessment was completed in April 2018 it was noted that ‘he has settled down with a partner and no longer goes out drinking with friends’. Shortly after this he began a new 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, stating that she had known him for six years. The reference did not mention the volatile nature of his relationship with his wife. It appears that the difficult ending to this relationship was known but was either not considered relevant as a private matter or because his own account of events not being his fault was too readily accepted. It was a characteristic of Mr. M. to present that he was ‘hard done to’ all the time so that people would feel sorry for him. The risk assessment, which relied on information about him settling down with a new partner, was not revisited when that relationship appears to have ended after a short period.

9.4.5   It was recognised that Mr. M. had no previous experience as a care worker. He undertook a number of appropriate training events during his employment and in many ways appears to have been well liked by those in his care. He would often go the extra mile to support them.

9.4.6   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 of the tasks being undertaken by him that involved him using her debit card. He was not authorised to do this and she had no suspicions that he might have been doing so.

In the light of the complaints about the state of the house by the TorrAGE manager, this could have been an unannounced visit without Mr. M. present to determine whether he was fully discharging his duties. The Registered Manager advises that the organisation does undertake unannounced visits to and obtain feedback from clients in order to monitor staff performance. She is doubtful that Ella would have allowed a separate visit of this kind and seen it as intrusive. However, it was not considered at the time and it was a welcome departure for the provider, given previous history, to have a care worker visiting regularly whom Ella liked.

9,4,7   Such a visit alone with Ella and a greater exercise of professional curiosity may have revealed that Mr. M. was going beyond his brief and raised suspicion. The care coordinator confined herself on this occasion to discussing solely what he was contracted to undertake. It was felt that TorrAGE was carrying out shopping tasks and that therefore this was not in the provider’s brief. But the TorrAGE worker was visiting once a week. A question as to how Ella obtained any shopping in the periods between could well have elicited information about Mr. M’s activities.

Learning point

9.4.8   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. Additionally, 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.

9.4.9   It is questioned whether Mr. M. was treated differently from other staff because of his relationship with the director, later former director, of the company. This was not overtly the case initially. For example, his probationary period was extended. He was also apparently a well-known and popular figure in the local community. At first sight it would appear that this and his ongoing relationship with the former director combined to allow him to evade suspicion when he began to abuse Ella. In retrospect his general demeanour is recognised as being manipulative and there is still shock that he went on to commit such a grave act of violence.

9.4.10 However, the work undertaken by the police on Mr. M’s phone during the murder investigation indicated that he 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. She had been aware of his drug issues at an earlier point and, when they moved to Spain, she tried to detox him off drugs. But upon coming back to the UK she was aware that he was still using. Both Mr. M. and his partner were in debt and there are text messages between the two indicating this. As she was both a former director and an active employee of the company, she had a safeguarding duty to disclose this information. The Registered Manager advised me that she at no point reported any information about his drug taking other than the two cautions which pre-dated his employment.

9.4.11 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.

9.4.12 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.

9.4.13 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.

9.5      Do the agencies and the provider have up-to-date policies in relation to preventing financial abuse?

9.5.1   It was important for Ella, being reliant on others to undertake her shopping and withdraw money, that agencies had appropriate procedures in place for handling of clients’ money. This was the case in respect of both TorrAGE and Complete Quality Care, the latter also having a gifts policy which they had brought to the attention of staff leading up to Christmas.

9.5.2   The Safeguarding Adults Partnership website has a page on financial abuse which can be accessed via the search engine or as a link from within the body of the multi-agency procedures.

9.5.3   Much of the focus recently has been upon the risk of financial abuse through scamming, cold callers and internet fraud. A Financial Abuse Evidence Review in 2015 [3] highlighted the prevalence of financial abuse by family members and care workers. It also references a study which “identified specific characteristics of family offenders who may perpetrate abuse, including relatives who had a drug or alcohol problem, ‘with financial struggles’ and those with a gambling problem.” (p.8) These characteristics are equally applicable to care workers.

9.5.4   The Kent and Medway Safeguarding Adults Board website contains a financial abuse tool kit including pages focussing on recognising someone at risk of and experiencing financial abuse and characteristics of potential perpetrators.

9.5.5   It is suggested that these are examples of resources that could be used both in learning events following this review and in enhancing partners’ guidance for staff in respect of the more personal form of financial abuse that was experienced by Ella.

9.6      Were there any equality and diversity considerations in relation to Ella and, if so, how were they handled?

9.6.1   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.

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

9.7.1   Mr. M. was not interviewed by the police between the allegation of financial abuse and when the murder took place. There is no record of him contacting the police himself. The police were advised by the Registered Manager of Complete Quality Care that he had accused the TorrAGE worker of the thefts.

9.7.2   The police IMR indicates that because Ella was considered a vulnerable victim, she 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. It was also believed that the keysafe number had been changed. It is not clear whether the officers considered that Mr. M’s. knowledge of the source of the allegation could be an additional risk factor.

9.7.3   The police were not informed that Mr. M had visited Ella after being suspended and instructed not to contact clients by the provider. 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. by the officer who had been allocated the crime. However, it is impossible to determine whether this may have deterred Mr. M, from returning to the house, especially as he visited Ella again within 36 hours.

[1] It is assumed from the wording in the IMRs that these are two separate occasions.
[3] Financial Abuse Evidence Review, Age UK Research, November 2015.

10. Good practice

10.1    Ella received a higher than average number of visits from Community Matrons 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 care package was modified on a number of occasions with agreement with the provider to find a balance between effectively meeting her healthcare needs and maintaining her cooperation. That this all occurred during the first nine months of covid 19 when home visiting was often restricted due to the risks of the pandemic is the more commendable.

10.2    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.

10.3    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.

Learning Point

10.4    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 (8.1), 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.

11. Recommendations

It is recommended that:

11.1      Care providers are briefed about the content of the SAR with 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

11.2    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.

11.3    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 positive measures have been put in place to mitigate risk.

11.4    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.

11.5.   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.

11.6    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.

11.7    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.

11.8    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.

11.9    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.

The author

Barrie Crook is a coach and consultant who is independent of the organisations involved in this review. From 2015-2021 he was the Chair of the Dorset and Bournemouth, Christchurch and Poole Safeguarding Adults Boards. Prior to this, he was the Chief Executive of Hampshire Probation Trust.


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