SAR Erik

Glossary of terms

Glossary of terms

Torbay & Devon Safeguarding Adults Partnership (TDSAP) was founded in 2021 by Devon County Council and Torbay and South Devon NHS Foundation Trust as a requirement of the Care Act 2014. It provides strategic leadership for safeguarding adults across Torbay & Devon. TDSAP is the collective name for partners across Torbay and Devon and acts as the key mechanism for agreeing how partner agencies work together to safeguard and promote the safety and wellbeing of adults at risk and/or in vulnerable situations. It does this by coordinating the operational work of TDSAP members and ensures this is done effectively.

The Care Act 2014 – helps to improve people’s independence and wellbeing. It makes clear that local authorities must provide or arrange services that help prevent people developing needs for care and support or delay people deteriorating such that they would need ongoing care and support.

Social Care Institute for Excellence (SCIE) – seeks to improves the lives of people of all ages by co-producing, sharing, and supporting the use of the best available knowledge and evidence about what works in practice.

SAR Quality Markers – a set of standards covering the whole process from initial decision making about whether a case meets the statutory criteria for a SAR, to evaluating the impact of actions taken in response to the learning identified.

National Network of SAB Independent Chairs – The Care Act established Safeguarding Adults Boards (SAB) in law. The Care and Support Statutory Guidance that accompanied the Act, set out expectations of those who chair Safeguarding Adults Boards. Where possible the chair should be independent, but this is not a requirement, and the network opened membership to all SAB chairs in 2016, having been set up as a peer support group for independent chairs in 2009.

Appendix 2’s – The purpose of the Appendix 2 is to gain an overview of events and changes in an adult’s life, including any relevant information regarding their wider family including any children they parent or care for.

Individual management report – The aim of the individual management report is to review the circumstances at the time; and to develop an open critical analysis of both individual practice and organisational policy and practice, to see whether the case indicates that changes can and should be made.

ViST – Vulnerability Screening Tool – process of identifying vulnerabilities, grading of the risk and signposting to relevant agencies.

s.42 Safeguarding Adults enquiry – action that is taken (or instigated) by a local authority, under Section 42 of the Care Act 2014, in response to indications of abuse or neglect in relation to an adult with care and support needs who is at risk and is unable to protect themselves because of those needs.

Multi-Disciplinary Team (MDTs) are the mechanism for organising and coordinating health and care services to meet the needs of individuals with complex care needs. These teams bring together the expertise and skills of different professionals to assess, plan and manage care jointly. Based in the community, and networked with primary care, MDTs are expected to work proactively to support individuals’ care goals.

Devon Adult Social Care – Social care staff who work with adults in Devon for whom activities of daily living (because of illness, older age, or a disability) can be difficult.

Care needs assessment – a structured process to assess potential need for day-to-day help

Devon Partnership Trust (DPT) – provide a range of specialist mental health, learning disability and neurodiversity services for the people of Devon, the wider Southwest region and nationally.

Mental Health Assessment & Review Team (MHAR) – a DPT team who manage new referrals and provide a single point of assessment and access to adult community mental health services across Devon.

MIND – a national charity who advice and support to empower anyone experiencing a mental health problem. MIND campaign to improve services, raise awareness and promote understanding.

Sovereign Housing – a housing association, primarily based in the South of England.

Devon & Cornwall Police Basic Command Unit (BCU) – the largest area of geographical command within policing, sub divided into district & local policing teams.

National Crime Recording Standards (NCRS) – NCRS has twin aims of being victim focussed and maintaining consistency of recording across all forces. It is based on applying legal definitions of crime to victim’s reports.

National County Lines Coordinating Centre – A national policing body comprising of The National Crime Agency, National Police Chiefs Council & Regional Organised Crime Unit, developing the national intelligence picture of the complexity and scale of the threat, prioritise action against the most serious offenders, and engage with partners across government.

Acceptable Behaviour Contract is a voluntary written agreement which is signed by an individual committing anti-social behaviour. In signing the contract, the individual is agreeing to abide by the terms specified and to work with the relevant support agencies.

EDP Drug & Alcohol Services support people to address their drug & alcohol misuse

Devon Integrated Care Board/Partnership (ICB) – formally Clinical Commissioning Group (CCG). Integrated Care Partnerships (ICPs) are collaborative networks of service providers. They include healthcare professionals, such as doctors, nurses, pharmacists, social workers, and hospital specialists; the voluntary and community sectors; local council representatives; and service users and carers.

1. Introduction to a Safeguarding Adults Review

1.1 The Torbay & Devon Safeguarding Adults Partnership (TDSAP) commissioned a safeguarding adults review (SAR) around the death of Erik, aged 48, who was found hanging from scaffolding in Exeter on the 1st April 2021.

1.2 Local agencies had been engaged with Erik over a number of years, and the TDSAP SAR Core Group, a subgroup of TDSAP responsible for overseeing the referral & management of SARs across Torbay & Devon believed that the circumstances leading up to his death met the statutory requirements for a Safeguarding Adults Review under Section 44 of The Care Act 2014.

‘A review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if –

a.              there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and

b.              the adult had died, and the SAB knows or suspects that the death resulted from abuse or neglect…’

1.3 Following the initial referral by Devon & Cornwall Police, and decision to undertake a review, a lead reviewer was appointed to work with relevant agencies to identify areas of learning to improve partnership working and to minimise the possibility of a reoccurrence, as per s.44(5) The Care Act

1.4 This review has attempted to follow as far as possible the Quality Markers for Safeguarding Adults Reviews as produced by Social Care Institute for Excellence (SCIE) and the National Network of Safeguarding Adults Board Independent Chairs.

1.5 The lead reviewer is a retired Chief Superintendent, Devon & Cornwall Police & a former Head of Public Protection. He is currently an Independent Chair of a Southwest Safeguarding Adults Board. Although a local policing commander in the relevant area, this was prior to 2015-6, 5 years prior to Erik’s death.

1.6 QM Marker 2.3 – Is there transparency about any conflicts of interest and how they have been managed?

The TDSAP Business Manager did identify a potential conflict of interest because of 1.6, but in discussion with lead reviewer, it was identified that although a member of Devon & Cornwall Police for 30 years, there was no connection with Exeter since 2016, and had been retired for 15 months on Erik’s death.

1.7 At the time of this report, there are concurrent processes ongoing. An inquest into Erik’s death has yet to be completed and there is also a single agency performance process still awaiting finalisation. Although this latter process has necessitated an amended review methodology, neither process is believed to impact on the learning & recommendations of this report.

1.8 Erik’s last surviving relative, his mother recently passed away. Due to illness, prior to her death, it was decided not to directly approach her for background into Erik’s life. However, the author is extremely grateful for the valuable family background in part 3 of this report gleaned from long standing family friends.

2. Review methodology

2.1 A Safeguarding Adults Review is more than a written report. It is a process which galvanises people & organisations who worked/are working directly with people who needed support to have a ‘duty of candour’, how they are open to learning, identify where improvements can be made & transparent in recognising barriers to effective practice.

2.2 An analysis of the Care & Health Improvement Programme led thematic work of SARs (2020, Preston-Shoot, Bray et.al) identifies key elements of an effective SAR.

(1) Legal literacy as to when a SAR is required (mandatory) or where it is believed valuable learning is beneficial to the safeguarding system (discretionary)

(2) Open, detailed & timely responses by agencies documenting not only the extent of their engagement with the person, but an openness in identifying learning at an early stage.

(3) Effective communication & involvement with/of family members or those representing the family of the person subject to the review.

(4) A process where the lead reviewer can engage with practitioners and managers, either individually or as a group where systemic analysis can take place.

(5) A review where there is good concordance between rationale for referral, terms of reference & identification of key areas through the above analysis.

(6) Drawing on learning from previous SARs where similar issues were identified.

(6) Areas of learning & recommendations that are co-produced, evidenced-based, learning focused & timely. Reviews should not ‘shy away’ from proposing system improvement regionally and/or nationally where appropriate.

2.3 The review into the untimely death of Erik has been identified as a mandatory SAR. Although not formally being provided with care & support as defined under The Care Act 2014, it is recognised through initial analysis of agencies responses that Erik was a person who required care & support, that he had died from abuse or neglect (including self-neglect) & there was reasonable cause for concern about how the SAB members of it or other persons with relevant functions worked together to safeguard Erik.

2.4 The documentation from agencies, either an Appendix 2 or Individual Management Report (IMR) allowed the lead reviewer to identify key areas of focus for further analysis, identified areas where learning could be implemented, and were open in how the safeguarding process could have been improved. It is important to state that, although there are areas of learning for the safeguarding system across Torbay & Devon, no apparent omission has been identified that could have prevented Erik’s death.

2.5 Section 3 will outline Erik’s family history, and how this may have contributed to attitudes, behaviours and engagement with agencies looking to help him.

2.6 Section 4 comprises of key elements of agencies engagement with Erik, drawing out some consistent themes of how they responded or otherwise to him as a person who had suffered trauma in childhood.

2.7 This review did not include a practitioner’s event. Although this is routine in many SAR processes, there were sound reasons why this did not take place. However, the positive engagement of agencies, particularly around learning and co-production of recommendations has overcome the potential direct learning from a practitioner’s event. In this specific case, given that a number of agencies would not have had direct involvement of Erik, some key discussion areas would have been hypothetical, and not based on Erik as a person receiving a safeguarding offer.

3. Family background of Erik

3.1 Although Erik did not see himself as being of mixed race, his mother was born, & lived for a long time in Jamaica before emigrating to the UK. Erik’s father was Austrian. Erik was born in the UK, but never saw his father.

3.2 There have been a number of significant tragic events in Erik’s life that may have contributed to a lifestyle or certain behaviour. Around the age of 5 or 6, Erik’s father died from drowning. Erik had an elder sibling. This elder sibling, seen as a ‘father figure’ to Erik also tragically died whilst flying a light aircraft. His death would have significantly impacted on him.

3.3 Erik’s mother was the one stable feature in his life. Over the last few years, she had become increasingly ill, leading to residential placements. This stability, that Erik had for much of his life, through his mother has ebbed away over recent years, leaving Erik isolated & vulnerable.

3.4 Erik has been described as having had very poor social skills with mild/moderate learning disabilities. He was highly motivated for work, particularly gardening. Erik worked for a landscape gardener, an area in which he excelled & greatly enjoyed. However, this came to an end, which once again left Erik isolated. Although he was subsequently employed with a cleaning company, this ended abruptly through inappropriate behaviour.

3.5 Although Erik’s mother clearly identified with her ethnicity, it is felt by those who knew Erik, he did not perceive themselves as mixed race.

3.6 Quality Marker 2.4 indicates that ethnicity should be included in review considerations.

Is it evident how race, culture, ethnicity, and other protected characteristics as codified by the Equality Act 2010 have been considered?

3.7 A key element of the Equality Act 2010 is the public sector Equality Duty. The Equality Duty ‘ensures that all public bodies play their part in making society fairer by tackling discrimination and providing equality of opportunity for all. It ensures that public bodies consider the needs of all individuals in their day-to-day work – in shaping policy, in delivering services ….’ (Equality Act 2010. A Public Sector Equality Duty)

3.8 There has been no information provided by agencies in this review, that race, culture, or ethnicity influenced any part of the service provided to Erik, notwithstanding that he himself did not perceive to be of mixed race. As lead reviewer, I cannot form a view as to whether engagement with Erik was influenced by ethnicity.

3.9 In reviewing templates used by TDSAP, specifically Appendix 1, Appendix 2 & Individual Management Review, there is no ‘signpost’ for agencies to consider whether race, ethnicity or any other protected characteristic was considered. As a partnership made up of public bodies, it is incumbent on the TDSAP to meet its requirements under the Equality Act 2010.

Recommendation 1. Within 3 months, the TDSAP includes in its SAR reporting mechanisms a section for agencies to provide a specific response regarding protected characteristics in its considerations & whether there is any related learning in the safeguarding practice it provided through the lens of The Equality Act 2010.

4. Summary of agency engagement with Erik

Key events around agency engagement with EH.

Direct comments from agency responses in italics

(i)             Devon & Cornwall Police.

21/06/19 – Criminal damage to Erik’s property. Suspect not identified. ViST* completed – low risk

13/07/19 – Assault victim, victim unidentified, Victim Needs assessment graded as low. First mention of Erik as victim of ‘cuckooing’. Erik later withdrew support for a Police investigation and the crime was filed No Further Action.

05/08/19 – Male & female has taken over Erik’s house. Police called, people removed. Risk graded as medium. Comment from police IMR – Individuals involved are local and not associated with County Lines Gangs.

30/10/19 – 30/06/20 – Due to safeguarding concerns, a Safeguarding Adults Enquiry was recorded. This led to numerous visits by the local Police Neighbourhood Team to ensure Erik was safe. Some visits included attendance of Housing Officer. Erik given a Cuckooing Escalation Letter, which highlighted risks of being a victim of cuckooing. Enquiry closed as it was believed risk of exploitation had been negated.

02/01/20 – Erik reported that people had entered house & stolen medication/phone. Erik withdrew complaint. Graded as medium risk. ‘Eric wants help with alcohol problems. Fears losing housing owing to problems at the address with unwanted visitors.’

28/09/20 A second Safeguarding Enquiry recorded due to people using house to sell drugs. Erik described as vulnerable due to alcohol dependency & learning difficulties. Erik given a Cuckooing Escalation Process Letter 2 & housing provider notified. Neighbourhood Police Manager arranges for alarm to be installed & a ‘dummy’ CCTV outside of house. However, it appears Erik continues to have people visiting house, both invited & uninvited. Evidence of Class A substance misuse. Due to false alarm activations, alarm removed. Enquiry closed at end of January 2021 as it is now considered Erik has withdrawn support for agency support. At this time Erik graded as ‘High risk’ of being exploited. ‘Erik is the victim of cuckooing, has care and support needs and previously been open to ASC’.

15/10/20 – Erik calls police due to 2 unwanted people entering house stealing phone. Housing association visit & change locks. Erik taken to place of safety. Although immediate safeguarding protected EH, people unidentified and no further investigative action took place. Crime was filed as ‘no further action’.

06/01/21 – Police visited Erik’s property as part of safeguarding enquiry. Erik found to be under influence of drugs, with 2 people staying in property. Concerns around Erik’s welfare & health referred to GP. Ambulance called to property as female found unresponsive. Named individuals believed to be staying at property. Risk identified as medium.

04/02/21 – Theft reported by Erik, people using Erik’s bank details to purchase goods totalling £647. Although individual suspected, no evidence to link named person to crime. Matter referred to Action Fraud.

(ii)           Devon County Council (Adult Social Care – ASC).

20/11/19 – Safeguarding Enquiry raised due to concerns raised by friend of Erik that they were vulnerable to ‘cuckooing’ & continuing to misuse alcohol. Safeguarding Adult hub contacted Erik. Erik asks for support as there are unwanted people staying at address & believes that a female who at that time was in prison, on release will move in. Although specific Social Worker (SW) allocated to case, no actual visit by SW, but assurance accepted that Erik was safe via telephone discussion with police officer.

29/09/20 – High risk (Red ViST) received by ASC by Police (Relates to D&C entry 28/09/20 above) Direct comment from Police in ViST A re-assessment of care and support needs may be necessary to establish how the above risks can be managed and how Erik can keep themself safe from future exploitation. ASC managers, using a draft waiting list escalation protocol decided that a Section 42 Enquiry to be progressed.

18/10/20 – 2nd ViST referred to ASC by Police.

20/10/20 – ASC enquiries limited to discussions with housing & police since receipt of 1st ViST.

28/10/20 – Directly taken from IMR ‘28/10/20202 MDT with GP, police, housing and minute taker.’ Although this would suggest a Multi-Disciplinary Team regarding Erik had taken place, it is believed that this was an instruction for social worker from a line manager. No evidence that an MDT had taken place

24/11/20 – Telephone call received by ASC from GP surgery. Direct from IMR ‘Erik says they do not go out very much, when they do gets very anxious, struggles with public, always looking over shoulder.  Erik explains because of the way they are, struggles to keep appointments & also not very good at paying bills.  Erik is hoping he can be contacted about any help or support you might be able to give him. This information was recorded on The Care First system, but no action taken.

03/12/20 – Further call to ASC regarding Erik’s vulnerability from a friend. Friend summarises Erik’s difficulties and ‘…would like to know if there is any help available for Erik’. Although information recorded on Care First, no follow up action in contacting friend

07/12/20 – Telephone call to Erik from allocated social worker. Recording of discussion limited to support for drug & alcohol use and help he has previously had. Given this is the first record of a direct discussion between allocated social worker & Erik since s.42 enquiry tasked, there is no information given around understanding or managing risks, exploration of health & social care needs or any narrative around a Care Needs Assessment.

08/12/20 – Safeguarding Enquiry closed as it was believed ‘the immediate risks are adequately addressed. Review by ASC has identified that adult safeguarding processes were not followed including an absence of understanding or exploration of the risks Erik faced, a lack of multi-agency working to enable robust risk assessment and long-term protection planning.

15/01/21 – Further ViST received from Police with clear information as to Erik’s current situation including social care support. Although recorded on the Care First system, there was no triage of need nor response to police referral.

10/03/21 – no services from DCC to review therefore close and inform to report to Care Direct if new episodes occur.

(iii)           Devon Partnership Trust (DPT).

07/04/2016 – Presented to Royal Devon & Exeter Emergency Department after being found on scaffolding by neighbour, intoxicated & threatening to hang himself. Direct narrative from assessment – Erik linked this to a build-up of low self-esteem, being taken advantage of by others, anxiety, low mood & social isolation. Also has vulnerabilities from past trauma and losses. Referred to MHAR (Mental health Assessment & Review Team) for psychological input to work on self-esteem & past trauma. Would benefit from further assessment of his needs including ADL (Activities of Daily Living) & query learning difficulties and some work on social inclusion.

18/04/2016 – MHAR declined referral based on ‘It would appear that alcohol remains a significant factor for risks and assessing whether there is a mental illness, whilst Erik continues to use alcohol as much as they do, would prove difficult. Certainly, current use of alcohol is likely to be affecting mood and psychology are unlikely to accept any referral to them, to work on past issues, whilst drinking continues.’ Outcome shared with RISE (drug & alcohol services)

19/06/2017 – Street Triage clinician contacts DEVON PARTNERSHIP TRUST to advise EH has been met by street triage – and is failing to attend appointments with RISE.

08/06/2018 – Police contact DPT following incident where mental health concerns were identified & seeking advice. Police advised to contact GP in first instance as consent was required & Erik not receiving mental health services.

11/06/2018 – Following self-referral to Liaison Psychiatry, Erik advised he was no longer experiencing suicidal thoughts. Has had fleeting suicidal thoughts over the past few weeks. Aware of how to get support if required – through Samaritans, GP and support worker. Advised to make appointment with GP to review medication and mental health. Advised to contact support worker to request support today.

(iv)          GP Surgery

10/2/20 – Erik attended surgery at GP request following safeguarding concern. Erik informed GP that he was generally well and attending Alcoholics Anonymous.

1/10/20 – GP contacted by ASC identifying concerns around ‘safety & vulnerability.  Of discussion recorded by surgery was that ASC would contact Erik for further assessment. This element was recorded retrospectively on ASC Care First, and it is unclear what, if any action was taken.

23/11/20 – Surgery received call from Erik requesting referral to social services for housing & financial support. Erik given self-referral number. Notes makes comment that ASC were following up, but Erik regularly disengages. Last noted contact between surgery & Erik.

11/1/21 – Surgery contacted DPT via email requesting invite to discuss further. Response that Erik not open to DPT services. Potential that this email had been sent to DPT rather than ASC Safeguarding Team. This message was redirected to ASC.

(v)            Sovereign Housing

22/01/2016 – Phone call from Erik’s mother, concerned Erik feeling suicidal. Recommendation that Housing Officer visit Erik and for Erik to GP and MIND.

20/12/2018 – Email trail between Housing Officer and Police confirming alarm had been fitted to the property and Housing Officer would be visiting later that week. Police also advised that there were several young people in Erik’s home who weren’t from Exeter and were using it as a base.

13/08/2019 – Joint visit between Police & Housing Officer due to concerns that two people had befriended Erik & were staying at the property. Erik identified as vulnerable person who had been previously exploited.

04/11/2019 – Police advised Housing Officer that the safeguarding team were aware. The Housing Officer ‘…did not attend the safeguarding meeting but was aware that Erik was in the safeguarding system at this point.’

15/11/2019 – Joint visit between the Housing Officer and the Police due to ‘cuckooing’ concerns. Due to concerns raised during visit further visits by the Police to check on his welfare arranged.

16/04/2020 – Housing Officer supplied copy of letter being sent by police to Erik and asking Police to hand deliver as he was unable to carry out visits due to lockdown restrictions.

I’ve been contacted by PC XX advising of concerns that you are allowing known alleged drug dealers access to your home. In the past, we’ve had discussions with you about allowing non-desirable people access to your home and allowing them to stay, and you agreed that you wouldn’t let this happen in the future. So, it’s really concerning to hear of recent events. You need to take steps to prevent this happening, and work with the police to help you to resolve this situation. I do hope that you will do this

A copy of this letter is being provided to the police. If you’d like to discuss this, please call me on 0300 5000 926.

09/07/2020 – ‘Although the Lockdown had ended, Sovereign’s interim service offer was that Housing Officers should only carry out home visits in an emergency situation, so visits were left with the Police to carry out’. There is a good record of joint working which demonstrates that in normal times these would have been joint visits.

29/09/2020 – Police send Cuckooing Letter 2 to Housing Officer. Relocation considered but it was felt there wasn’t a more suitable property for Erik. The Housing Officer and Police also felt that they were better able to keep an eye on him at his current address. They acknowledged that Exeter is small so there was a good chance that EH’s visitors would soon find them as they was often out in the city centre.

07/01/2021 – 22/02/2021 Following escalation of police concerns including drug misuse, condition of the property & people exploiting Erik, police & Housing Officer conclude that an Acceptable Behaviour Agreement is given to Erik. This was given to Erik on 22/02/2021.

24/02/2021 – Anti-social Behaviour (ASB) case created. Erik considered to be the perpetrator due to the undesirable people attending the property and drug activity.

5. Main learning points

5.1 Erik as a victim of ‘Cuckooing’

5.1.1 The initial referral from Devon & Cornwall Police identified that Erik was a victim of ‘cuckooing’ for some time before and at the time of his death. Further research into Erik as a victim of cuckooing identified that this particular form of exploitation had been a factor in his life since 2019.

5.1.2 ‘Cuckooing’ is described as:

… a practice where people take over a person’s home & use the property to facilitate exploitation*.

Primarily, criminals will use this person’s home for drug dealing, but other criminality such as violence & theft are often associated with cuckooing.

*Cuckooing. A joint approach – National County Lines Coordination Centre.

5.1.3 The National County Lines Coordination Centre has identified a number of specific heightened risk factors that make people vulnerable to cuckooing. Many of these directly relate to Erik.

(i)             Lack of safe/stable home environment.

(ii)            Social isolation or social difficulties.

(iii)           Economic deprivation.

(iv)           Insecure accommodation status.

(v)            Physical or learning disability.

(vi)           Mental ill health.

(vii)          Substance misuse.

5.1.4 Between June 2019 and April 2021, both Police & Erik’s Housing Provider, Sovereign Housing, singularly & jointly contacted or visited Erik after known reports of victimisation. This review has identified police officers followed their procedures in submitting ViST’s and/or recorded crimes in accordance with National Crime Recording Standards. Furthermore, Erik received letters from Devon & Cornwall Police in relation to an escalating threat as a victim. This is in line with Force policy where people have been identified as a victim of cuckooing. Erik was also supported through installation of an alarm, and a dummy camera. This is to be viewed as positive action in attempting to safeguarding Erik.

5.1.5 The primary focus of Devon & Cornwall Police response to the threat of exploitation faced by Erik was safeguarding, not investigation. The investigations of recorded crimes did not lead to any prosecution of any perpetrator. There were examples where Police Officers on visiting Erik, spoke to potential perpetrators and were able to ensure they left his property.

5.1.6 There were & continue to be a number of challenges faced by Police Officers in being able to prosecute potential perpetrators of cuckooing. Criminals identify people such as Erik to exploit for their own benefit as they can prove to be unreliable & reticent witnesses against them. Erik was inconsistent in his wish for support from agencies, and it is also clear that he was committing criminal offences himself, particularly the taking of illegal drugs.

5.1.7 Relying on people who are vulnerable as primary witnesses in cases of this type of exploitation will always prove challenging for prosecuting authorities. This is exacerbated through lack of legislation to support victims.

5.1.8 There is no specific offence for ‘cuckooing’ and in their report, entitled ‘Cuckooing. The case for strengthening the law against slavery in the home.’, The Centre for Social Justice corroborate the local challenges in prosecuting offences of this form of exploitation. The report highlights the evidential difficulties that Police Forces face in applying existing legislation to cuckooing. Section 1 of the Modern Slavery Act is the legislation that investigators are signposted to, but unless there is tangible evidence of ‘servitude, then ‘mere occupancy is inadequate to pursue a charge under s.1 of the Act.

5.1.9 Section 45 of The Serious Crime Act 2015 is another piece of legislation commonly identified as pertinent to cuckooing. However, this offence requires a minimum of 3 people acting in concert as part of an organised gang. Again, prosecuting in relation to this offence would be irrelevant in Erik’s circumstances as no more than 2 people at most were acting together.

5.1.10 Cuckooing is a key element of County Lines criminality. All national & local documentation refer to the exploitation of children & vulnerable adults as intrinsic to this type of crime. The legal framework is stronger and clearer in protecting children. Consideration of how this can be applied to the protection of adults who will invariably be in need care & support within the definition of The Care Act is vital if the statements made nationally & locally about the need to protect adults at risk ultimately lead to better outcomes for them.

Recommendation 2. Within 3 months, The TDSAP forwards this report to The Drugs Supply & County Lines Unit, The Home Office to enable it to be considered in its evidence gathering for potential legislative developments specifically around cuckooing.

Recommendation 3. Within 6 months, the 2 Devon based Basic Command Units carry out a case audit of people who are potential victims of cuckooing to ensure that related crimes are being investigated in a timely way with all proportionate investigative elements being considered, and that these crimes are receiving effective supervision, with a clear focus on bringing perpetrators to justice.

5.1.11 The response to cuckooing cannot be reliant on a single agency, nor law enforcement. This is particularly so when the legislative framework is limited. A multi-agency response to adult victims of exploitation needs to be supported by clear guidance for practitioners bringing together the various powers, skills & funding streams in a collaborative and person centric approach.

5.1.12 Both police officers & housing officers attempted to safeguard Erik. There are examples of good proactive action such as installing a dummy alarm, regular visits to Erik’s address, referrals to other agencies. It is clear that police officers & Housing officers did work together. However, the strategy in safeguarding Erik was not coordinated, it was limited & not escalated through line managers when it was clear that Erik continued to be exploited.

5.1.13 There are many local best practice toolkits that can be utilised to support victims of this specific type of exploitation, not only national partnerships, but local to Devon & Cornwall. Leicester Safeguarding Adults Board has a specific guide for practitioners working in a multi-agency environment to facilitate effective working with adults who are at risk due to cuckooing*. Locally there are guides that also seek to support adult victims of exploitation e.g., South Devon BCU.

Recommendation 4. Within 6 months, The TDSAP together with Safer Devon Partnership, Devon Children & Families Partnership and The Devon Anti-Slavery Partnership, consider how best to develop a multi-agency framework to enable practitioners to minimise the risk of adult victims of cuckooing being exploited. This framework to include data collection, potential powers that can be employed to disrupt or prosecute perpetrators, support available to victims, raising community awareness of exploitation & learning opportunities for practitioners.(The National County Lines Coordinating Centre is a potential source of valuable information for developing such a framework including national training packages.)

Recommendation 5. Within 3 months, the Chair of TDSAP uses the national SAB network escalation process to highlight the gaps in legislative & national guidance to safeguard adult victims with care & support needs who are at risk of being exploited through ‘cuckooing’.

*https://www.llradultsafeguarding.co.uk/guidance-for-working-with-adults-at-risk-of-exploitation-cuckooing

5.2 Erik as a person who experienced trauma as a child

5.2.1 The family background in section 3 clearly identifies that Erik, as a child, experienced trauma through the deaths of a father & a brother.

5.2.2 There are many variations on the term ‘trauma’ within the context of how certain events impact on a person as they develop. The following has been taken from the Trauma Informed Practice Toolkit, Scotland Government, (https://www.gov.scot/publications/trauma-informed-practice-toolkit-scotland/)

‘Individual trauma results from an event, series of events, or set or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being.’

5.2.3 The same document highlights that recognising & understanding how trauma impacts on a variety of life outcomes is well established & understood. How that understanding leads to embedded practice,

‘…requires a multifaceted, multi-agency approach that includes awareness-raising and education, upstream working, and effective trauma focused assessment and treatment. To maximise impact, all of these efforts will need to be made in a context that is trauma-informed, based on a sound understanding of trauma and its far-reaching implications.’

5.2.4 Responding to a person such as Erik who experienced trauma becomes more challenging when there is limited and periodic engagement with agencies, particularly if there is an absence of a multi-agency mechanism to coordinate supporting activity.

5.2.5 A review of the individual agencies who submitted responses to their engagement with Erik does not clearly identify that trauma informed practice, ethos or awareness formed part of individual or organisational thinking or plans in supporting him. There are examples where more consideration around Erik as a person who experienced trauma as a child and its long-term impact may have led to different actions. The issuing of an Acceptable Behaviour Contract (ABC) by Sovereign Housing and Devon & Cornwall Police Officers, although viewed at the time as being helpful for Erik to deter the people who was exploiting him from visiting him, did not consider how this may have led to feelings of further isolation & helplessness from the perspective of a victim.

5.2.6 Acceptable Behaviour Contracts are a preventative measure designed to address anti-social behaviour and are a useful tactic to prevent anti-social behaviour. Key elements of an ABC are:

(i) Although not legally binding, ABC’s can be used by agencies for further action if the anti-social   behaviour continues.

(ii) Where possible the individual should be involved in drawing up the contract. This may encourage them to recognise the impact of their behaviour and take responsibility for their actions.

(iii) Support to address the underlying causes of the behaviour should be offered in parallel to the contract. This may include diversionary activities e.g. counselling or support for the family. It is vital to ascertain which agencies are already involved.

(iiv) Legal action in the form of an anti-social behaviour order or possession order (if the person is in social housing) should be stated on the contract where this is the potential consequence of breach.

5.2.7 National guidance on Anti-social behaviour powers are punishment-led, and the current Anti-social behaviour statutory guidance for frontline professionals (updated in January 2021*) understandably focuses on victims. However, in examples where adults at risk of exploitation are being considered for punitive action to address their anti-social behaviour, great care is required to ensure that agencies are not exacerbating vulnerability nor adding further pressure on individuals through the threat of prosecution or eviction.

*Anti-social behaviour, Crime & Policing Act 2014. Anti-social behaviour powers. Statutory guidance frontline professionals.

Recommendation 6. Within 3 months, Devon & Cornwall Police and Sovereign Housing review their Anti-social behaviour guidance, including acceptable behaviour contracts to ensure that where people who are both victims of exploitation & potential perpetrators, their vulnerability & the requirement for safeguarding is clearly highlighted in strategy and/or working practice.

5.2.8 Likewise, the response of Devon County Council Adult Social Care (ASC) did not demonstrate an understanding or awareness of how the trauma experienced by Erik played out in his life and how this could have impacted on how he engaged with agencies trying to support him. The minimal interaction between ASC & Erik, and limited supervision does not enable any suitable exploration of how ASC considered trauma as an influencing factor in Erik’s life. The wider response by ASC will be explored further in the next section, with reference to the action plan ASC is implementing in response to their review of Erik. In analysing the most current plan provided to the review, although there is reference to ‘improving an understanding & awareness of making safeguarding personal’, it is recommended that there is work progressed on similar activity in relation to trauma informed practice.

Recommendation 7. Within 3 months, Devon County Council Adult Social Care managers ensures the action plan in response to their review of Erik’s case has a clear focus on trauma informed practice within any continuous development programme and their supervision practice.

5.2.8 A further recommendation in the next section enables the TDSAP to seek reassurance from DCC ASC that progress has been made with respect to this action plan.

5.2.9 A common challenge, one that is not unusual of a person with the lifestyle that Erik followed was consistent & regular engagement. This was apparent when analysing police, GP, Housing, Adult Social Care and Drug & Alcohol Services responses in this review. Providing an effective & supportive service to a person who misses appointments or is inconsistent in their needs can be difficult. This challenge, post coronavirus pandemic will only become more difficult as demand increases, but funding not increasing commensurately. Agencies who are commissioned to provide services need to show that they are not only providing an effective service, but one that is cost efficient.

5.2.10 The Scottish Government partners recognised that services needed to develop to maximise the engagement & involvement of service users who struggle to effectively manage their time:

‘The principle of choice was most commonly referred to in the context of appointment scheduling, issues relating to non-attendance, or the application of discharge policies. Most services highlighted the need for maximum flexibility, with some services responding to high rates of nonattendance by modifying their practices and procedures multiple times. One service described a practice of operating “under the radar”, keeping clients on the books when formal policy dictated that they should be discharged due to non-attendance.’

5.2.11 Although processes have changed since their respective engagement with Erik ended, partners such as Devon Partnership Trust and EDP Drug & Alcohol Services may wish to review how their current referral processes or attendance & engagement systems are informed through a trauma informed lens, including an engagement/re-engagement process.

5.2.12 It is well documented that trauma can inhibit a person’s learning. This can be exacerbated at an early age.

5.2.13   Learning Disability Today highlight the potential impact on development from trauma which can lead to learning disabilities.

(i)             It interferes with thinking and if you have an intellectual disability thinking was already hard. It is known that traumatic childhoods lower academic potential.

(ii)            It destroys trust in other people.

(iii)           It makes people difficult to understand

(iv)           It makes it difficult to understand the person with learning disabilities.

(v)            Often the learning disability itself is seen as being the reason for why people behave the way that they do (distressed people hurting themselves, hurting other people). Yet, the learning disability doesn’t make people behave in strange ways. It is the trauma that leads to the behaviours and these need to be understood if we’re going to try to help people to cope with their difficulties.

5.2.14 In the context of 5.2.14 and specifically Erik, there was an assumption that Erik could read & understand written communication, or that Erik would respond in a certain way to letters indicating a cessation of support. When there was inconsistency in his engagement with agencies or no response, there appears to be no consideration of how early trauma could have led to a mistrust of statutory agencies.

5.2.15 A number of Local Authorities are developing a trauma informed approach across their departments and wider partners. Within the Southwest, Plymouth City Council, together with its partners are seen as a leading trauma informed regional Local Authority. Torbay Council is also developing a strong approach to trauma informed practice.

5.2.16 The Scotland document highlights that:

‘The journey towards becoming a trauma-informed organisation will require organisations to move beyond their traditional models of service delivery and to re-evaluate their entire organisational practices and policies through a trauma-focused lens.’

5.2.17 Devon has a trauma informed network, informal in nature where the focus is on partners receiving presentations to develop confidence & competency in trauma informed practice. There is recognition that Devon as a geographical Local Government structure is different to its unitary neighbours & coordination of a Devon-wide approach will require work as to how a more structured & tangible approach develops. It is not clear how information regarding the network is promulgated to partners across Devon, nor how aware they are of its existence, the value in the network as it currently works, and whether there is strategic acceptance that trauma-informed is the multi-faceted approach Devon wishes to take.

5.2.18 Devon County Council has a number of priorities as part of its 2021-2025 strategic plan where trauma informed practice can contribute to the overarching aim of ‘living well’ such as tackling Poverty & inequality, improving health & wellbeing and helping communities to be safe, connected & resilient. If Devon is to keep pace with other areas in delivering a coherent, consistent approach to developing & implementing trauma-informed practice, providing the best possible support to those who need it most, then it needs to consider how this is progressed at a strategic level.

Recommendation 8. Within 6 months, the Chair of the TDSAP shares the learning of this review, in particular around Trauma Informed Practice with Devon County Council Cabinet Members for Children Services & Integrated Adult Social Care & Health. This recommendation is aimed at starting a discussion at a strategic level as to how trauma informed awareness & practice is developed in a cogent & outcome focused way across Devon.

Recommendation 9. Within 6 months, the TDSAP seeks assurance from partners that their service delivery models, both as a single agency and working in partnership with others are in line with a trauma informed approach, including how processes are in place to maximise continued engagement & re-engagement with service users and how communication methods are tailored to the individual to ensure understanding.

5.3 Erik as a service user with complex needs.

5.3.1 In 2019, the then Devon Safeguarding Adults Board published a review into the death of ‘Rita’. The key themes from this review included:

(i)             Understanding other organisations roles and referral criteria

(ii)            Missed safeguarding opportunities pre and post Care Act

(iii)           Information sharing across agencies who use different systems to understand and respond to risk

(iv)           The need for a multi-agency forum to discuss complex individuals where professionals can understand and share the risks to these people.

5.3.2 Recommendations from this review included:

(i)             Whole system acknowledgement that when working with people with complex needs whom professionals, services and agencies find difficult to support; there needs to be joined up support and planning which ensures the most effective engagement to the persons unique circumstances.

(ii)            A multi-agency risk management forum should be put in place in Devon to consider cases of complexity and risk such as self-neglect and other high-risk situations, where staff are struggling with how to manage or reduce the risk.  To support practitioners, a multi-agency risk management forum would require senior level representation and offer a fresh approach with creative solutions, access to specialist support and legal advice where appropriate.

(iii)           Review Safeguarding processes to ensure:

An escalation protocol is developed and agreed and that staff with own agency are aware if it through it being circulated widely.

Staff can identify concerns in relation to self-neglect and have the confidence to act on their levels of concern knowing what to do about this. Staff are clear when they should and can share information.

These themes & recommendations equally apply to Erik as ‘Rita’.

5.3.3 Section 4 outlines the number of agencies that were engaged with Erik at some time in their adult life. Erik displayed some challenging behaviour for agencies such as inconsistent needs, missed appointments, aggression & behaviour driven by alcohol. On occasions, Erik asked for help, at other times the offer of help was declined.

5.3.4 It must be noted that the last year of Erik’s life was within the coronavirus pandemic. All agencies that were either engaged with Erik or received a referral were dealing with unprecedented circumstances. A further challenge for such agencies is that the value of their work is through face-to-face engagement with service users. National legislation & local policies placed additional difficulties on practitioners in undertaking their responsibilities throughout this period.

5.3.5 Erik was a person who experienced mental health challenges, but although assessed in 2016 by the mental health & review assessment team, it was believed that alcohol was the predominant factor affecting mood & behaviour.

5.3.6 Erik received support from EDP Drug & Alcohol Services in 2018 but this service was closed after he failed to respond to letters & texts.

5.3.7 Erik was a victim of crime on multiple occasions and was clearly seen as an adult being exploited in their own home. No person has been prosecuted for any of these crimes.

5.3.8 Sovereign Housing Association provided Erik with home accommodation. Housing officials were aware of his vulnerability, provided support within their sphere of influence, and attempted to engage other agencies, at times without success.

5.3.9 Devon County Adult Social Care received referrals & requests for potential care & support. Although a s.42 enquiry recommended, adult safeguarding processes were not followed, leading to a premature decision to close the safeguarding enquiry.

5.3.10 Erik’s GP surgery has provided a comprehensive record of engagement with him. The record shows a number of missed appointments. Referrals were made to other agencies but limited follow up to ensure these referrals were received.

5.3.11 Although the pandemic has played a part in the service that was provided to Erik, there are questions as to whether the partnership safeguarding response ‘made safeguarding personal’. Furthermore, in discussion with agency leaders, there is recognition that practitioners should have escalated Erik’s case when referrals were not progressed or when there was a lack of communication. Devon & Cornwall Police, Erik’s GP & Housing made multiple referrals to ASC. Although the information received by ASC was recorded, little or no action was taken. Given the level of exploitation and ongoing concerns for Erik, there were missed opportunities for agencies not only to follow up on these referrals, but to escalate to their respective line managers.

5.3.12 An escalation protocol was developed by The TDSAP because of the above recommendation from ‘Rita’s’ review in October 2021 with the following overarching aim:

‘The aim of this protocol is to resolve professional disagreements relating to the safety of adults at risk, escalating any concerns that may arise, if issues are not viewed as being dealt with satisfactorily.’

5.3.13 Delivering on positive outcomes for people at risk depends on an open & honest approach, not only at organisational level, but equally important, individual practitioners. It is incumbent on leaders to instil a culture of professional & respectful challenge. The current escalation protocol sets out an effective process for senior leaders, managers & practitioners. It is noted that this protocol was published after Erik’s death, but in publishing this report, it is recommended that the TDSAP uses this opportunity to reinvigorate the policy in a series of key messages to all Partnership agencies & staff.

Recommendation 10 Within 3 months, The TDSAP re-promotes its Safeguarding Adults Escalation Protocol to Partnership agencies and includes key messages from this document within a ‘lessons learnt from ‘Erik’’ learning brief to practitioners & managers.

5.3.14 A section 42 enquiry was not undertaken in respect of Erik. This was a missed opportunity to provide Erik with a coordinated & focused review of his care & support needs.  ASC did not act in a timely way, nor demonstrated professional curiosity to ensure that Erik was appropriately assessed for those needs. Supervisory oversight of the information being received regarding Erik & action being taken was also lacking.

5.2.15 Managers in Devon County Council Adult Social Care readily accept that the response to referrals & engagement with Erik was flawed and have developed an action plan that seeks to address areas such as improving recording discussions, supervision practice & improving understanding of making safeguarding personal.

5.3.16 In support of recommendation 7, it is also proposed that TDSAP seeks reassurance from DCC ASC that progress has been or is being made.

Recommendation 11 Within 6 months, TDSAP seeks reassurance from Adult Social Care that demonstrable progress has been made in relation to their action plan and seeks a timescale for any outstanding activity for this plan to be completed.

5.3.17 To support practitioners in multi-agency risk management forum, and to address recommendation 5.3.2 (ii) above, a pilot was undertaken in Exeter during 2019/2020 entitled Creative Solutions. This pilot has now ended, and currently there are no existing processes in place in support of the above recommendation.

5.3.18 The challenge of supporting people with complex needs where statutory or local commissioning eligibility is not met, appears to continue across Devon.

5.3.19 The footprint comprising Devon County Council is a large & complex geographical area, consisting of 6 districts, 4 Devon Integrated Care Board Local Care Partnerships and 9 policing sectors. Providing consistency in such an environment when there are many local & complex networks can be challenging

5.4.20 There is already a clearly established integrated model of working across Devon with Core groups of health and social care staff who can and do hold multi-disciplinary team meetings for people who have complex needs. In such a complex landscape, the value of local partnerships cannot be overestimated.

5.3.21 Although there is ongoing work in consideration of a multi-agency risk management to progress the recommendation from Rita’s review, TDSAP needs to reflect on the lack of progress of this work. The below recommendation seeks to build on Rita’s review, but with shortened timescales to provide impetus in moving from discussion and preparatory thinking to demonstrable improvement in safeguarding outcomes for people with complex needs.

Recommendation 12 The TDSAP at its December 2022 Board meeting accepts the following 3-part recommendation:(i)             By 31st December 2022, the TDSAP instigates a task & finish group to clearly understand the need for a multi-agency risk management process to safeguard people with complex needs who do not meet eligibility criteria for statutory or local commissioning support. This initial phase of work to include what currently exists across the Devon County Council footprint, and examples of similar work across the UK.(ii)            By 31st March 2023, the task & finish group provides the TDSAP with options as to how this cohort of people can best be safeguarded across Devon.(iii)           By 31st December 2023, TDSAP is implementing its preferred option with tangible improvement in safeguarding outcomes for people with complex needs who are not within statutory or local commissioning processes.

6. Appreciation

6.1       I would like to thank the agencies who have contributed to this review. I have found them to be open to how the safeguarding system across Devon & Torbay could be improved in the light of reviewing their own offer to Erik. I would also like to thank the 2 family friends for providing valuable information on Erik’s family background. Without their help, this review would not be able to give it the context of Erik’s formative years & how this may have influenced his lifestyle.

Appendix 1 – Table of recommendations

	Recommendation	Agency	Timescale
1	TDSAP includes in its SAR reporting mechanisms a section for agencies to provide a specific response regarding protected characteristics in its considerations & whether there is any related learning in the safeguarding practice it provided through the lens of The Equality Act 2010.	TDSAP	3 months
2	TDSAP forwards this report to The Drugs Supply & County Lines Unit, The Home Office to enable it to be considered in its evidence gathering for potential legislative developments specifically around cuckooing.	TDSAP	3 months
3	The 2 Devon based Basic Command Units carry out a case audit of people who are potential victims of cuckooing to ensure that related crimes are being investigated in a timely way with all proportionate investigative elements being considered, and that these crimes are receiving effective supervision, with a clear focus on bringing perpetrators to justice.	DCP	6 months
4	The TDSAP together with Safer Devon Partnership, Devon Children & Families Partnership and The Devon Anti-Slavery Partnership, commission a multi-agency framework to enable practitioners to minimise the risk of adult victims of cuckooing being exploited. This framework to include data collection, potential powers that can be employed to disrupt or prosecute perpetrators, support available to victims, raising community awareness of exploitation & learning opportunities for practitioners.	TDSAP SDP Devon SCP ASP	6 months
5	Chair of TDSAP uses the national SAB network escalation process to highlight the gaps in legislative & national guidance to safeguard adult victims with care & support needs who are at risk of being exploited through ‘cuckooing’.	IC TDSAP	3 months
6	Devon & Cornwall Police and Sovereign Housing review their Anti-social behaviour guidance, including acceptable behaviour contracts to ensure that where people who are both victims of exploitation & potential perpetrators, their vulnerability & the requirement for safeguarding is clearly highlighted in strategy and/or working practice.	DCP Sovereign Housing	3 months
7	Devon County Council Adult Social Care managers ensures the action plan in response to their review of Erik’s case has a clear focus on trauma informed practice within any continuous development programme and their supervision practice.	DCC ASC	3 months
8	Chair of the TDSAP shares the learning of this review, in particular around Trauma Informed Practice with Devon County Council Cabinet Members for Children Services & Integrated Adult Social Care & Health. This recommendation is aimed at starting a discussion at a strategic level as to how trauma informed awareness & practice is developed in a cogent & outcome focused way across Devon.	IC TDSAP	6 months
9	TDSAP seeks assurance from partners that their service delivery models, both as a single agency and working in partnership with others are in line with a trauma informed approach, including how processes are in place to maximise continued engagement & re-engagement with service users and how communication methods are tailored to the individual to ensure understanding.	TDSAP & partners	6 months
10	TDSAP re-promotes its Safeguarding Adults Escalation Protocol to Partnership agencies and includes key messages from this document within a ‘lessons learnt from ‘Erik’’ learning brief to practitioners & managers.	TDSAP	3 months
11	TDSAP seeks reassurance from Adult Social Care that demonstrable progress has been made in relation to their action plan and seeks a timescale for any outstanding activity for this plan to be completed.	TDSAP	6 months
12	The TDSAP at its December 2022 Board meeting accepts the following 3-part recommendation: (i)             By 31st December 2022, the TDSAP instigates a task & finish group to clearly understand the need for a multi-agency risk management process to safeguard people with complex needs who do not meet eligibility criteria for statutory or local commissioning support. This initial phase of work to include what currently exists across the Devon County Council footprint, and examples of similar work across the UK. (ii)            By 31st March 2023, the task & finish group provides the TDSAP with options as to how this cohort of people can best be safeguarded across Devon. (iii)           By 31st December 2023, TDSAP is implementing its preferred option with tangible improvement in safeguarding outcomes for people with complex needs who are not within statutory or local commissioning processes.	TDSAP	31/12/22     31/03/23   31/12/23

Appendix 2 – Terms of reference for review

Background to review.

This safeguarding adult review (SAR), commissioned by the Torbay & Devon Safeguarding Adults Partnership (TDSAP) surrounds the death of Erik, aged 48. Erik died on the 1^st April 2021 in the Exeter area, where he lived.

Although no formal record of death has been established through an inquest at the time of this review, the cause of death as recorded on the post-mortem report is asphyxia due to hanging.

Prior to his death, Erik was known to a number of agencies, including those relating to substance addition. Erik was also believed, due to his vulnerabilities to have been a victim of ‘cuckooing’ over recent years.

The initial referral to the TDSAP was made by Devon & Cornwall Police on the 12^th April 2021.

TDSAP considered the referral at its Safeguarding Adults Review Group (SARG), agreeing that the pre-requisites for a mandatory safeguarding adult review under the Care Act 2014 had been met.

Preliminary action by TDSAP.

TDSAP asked members of its SARG to identify those agencies who had a level of engagement with Erik that would facilitate an effective review. The following agencies were identified.

• Devon & Cornwall Police.
• Devon County Council – Adult Social Care.
• Devon Partnership Trust – mental health services.
• Drug & Alcohol Services.
• Southernhay House Surgery – General Practitioner.
• Sovereign Housing Association.
• Southwest Ambulance Service Foundation Trust.
• Royal Devon & Exeter NHS Foundation Trust.

All above agencies provided an Appendix 2.

The purpose of the Appendix 2 is to gain an overview of events and changes in an adult’s life, including any relevant information regarding their wider family including any children they parent or care for.

Following the receipt of Appendix 2’s, a number of agencies submitted an Individual Management Report (IMR).

AN IMR is intended to provide a review of decisions, actions taken, and services provided to a person, who is the subject of a SAR. The aim of the individual management report is to review the circumstances at the time; and to develop an open critical analysis of both individual practice and organisational policy and practice, to see whether the case indicates that changes can and should be made.  If the need for change is indicated, the report author can identify how those changes will be brought about.  If a change in policy and practice has already occurred, the report author must document and evidence this thoroughly.

• IMR’s were provided by;
• Devon & Cornwall Police.
• Devon County Council.
• Devon Partnership Trust.
• Southernhay House Surgery (GP)

 Methodology.

The TDSAP have developed a structured process for identifying the ‘best fit’ methodology for producing a review that maximises the learning from a tragic event such as the death of Erik. It must be noted that a review is more than a final report. The review process, including collating information, involvement of the family, engagement & consultation with both practitioners & managers and drawing from previous learning are equally as important as a final report.

The options as identified by TDSAP for the review process includes.

Significant Event Analysis or Multi Agency Case Audit (MACA): This approach brings together managers and / or practitioners to consider significant events within a case and together analyse what went well and what could have been done differently, producing a joint action plan with recommendations for learning and development.

A Themed Systems Review: The ‘systems’ model has been identified as a means of identifying which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. A number of SARs with similar themes can be grouped together to review and identify consistent system learning. It is a collaborative model for case reviews – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.

A review using Individual Management Reviews to Analyse Performance: Individual Management Reviews (IMRs) are intended as a means of enabling organisations to reflect and critically analyse their involvement with key individuals in the case under consideration, identifying good practice, and that where systems, processes, individual and group practice could be enhanced. Individual Management Reviews can be used either as a tool of their own in a SAR or as part of a more detailed review.

A multi-agency Combined Chronology review: Developing a chronology of events is a useful way of achieving an overview of a case or situation and considering the areas for development or change. With a combined chronology, this perspective is greatly enhanced and enables us to identify not only gaps in service provision(s) or practice, and therefore areas for development, but also missed opportunities for communication between agencies.

A traditional SAR approach, using a Combined Chronology, Individual Management Reviews and a Review Panel: It maybe that the Subgroup considers that the best way addresses a complex case if for the agencies concerned to participate in a review that follows the model of a traditional SAR.

Although 5 distinct methodologies have been adopted by TDSAP, a lead reviewer can adapt a review process that can take a number of elements from the above methodologies that will draw out the best available learning for individual agencies and/or partnership system to take forward.

Following an initial review of submitted Appendix 2’s & IMR’s, the proposed methodology for Erik’s review is as follows.

• Review of IMR’s provided to the lead reviewer to identify any learning already identified, any action that has already been taken as a consequence of their involvement with Erik, & any recommendations identified by the agency. This element of the process will also, through an analysis of Appendix 2’s, identify any further IMR’s that may need to be produced by other agencies & key areas to focus review on e.g. exploitation.
• Where there has been a service provided to Erik over a number of years by a specific agency, a chronological review will analysis that service over a longer time period to identify the consistency of service, any best practice delivered over that time, or any improvements that could be made from the challenges from providing a longer-term service e.g., continuity of staffing, line management.
• A review of any national or local policies, guidance, working practice that is relevant to the harm or risk of harm posed to Erik e.g., ‘cuckooing’. Following this review, a practitioner event to analyse how these strategies/guidance/working practices were implemented for Erik.
• Underpinning the above, the direct involvement of Erik’s family so that Erik’s voice can be heard during this review, and the family’s perspective as to how agencies supported Erik both as individual agencies & as a partnership.

Terms of reference.

The primary function of this SAR will be to draw together the critical learning which identifies any systemic issues & learns lessons for the future and identifies any necessary action. It will also consider what the relevant agencies involved in the case both did well in mitigating risk of harm to Erik, but also what might have done differently that could have prevented harm/risk of harm.

There appears to be 3 primary areas of Erik’s life that posed significant risk, namely exploitation, mental health & alcohol dependency.

The first concern raised around risk of exploitation occurred in October 2019. The review will analyse the service provided to Erik to protect him from such harm, will be from this time to his untimely death in April 2021.

Although Erik was diagnosed with psychotic depression in 2006, at no time since 2014, was Erik engaged with secondary mental health services through Devon Partnership Trust. The relationship between mental health & alcohol misuse is a key element of Erik’s life to be explored. In April 2016, the Mental Health Assessment & Review Team did not feel that they were the right service to support Erik, indicating that alcohol misuse was his primary difficulty. The review will explore the relationship between mental health & alcohol misuse in Erik’s life from April 2016 & how this defined the type & level of service Erik received.

Within the time parameters set above the review will consider & seek to address.

• Understanding of the person: How well was Erik understood as an individual with his own needs and aspirations. To what extent was this recorded/communicated?
• Are there any national or local working practices/guidance or policies that are relevant to Erik? How well were these implemented for Erik? Were the services available to Erik commensurate with risk & provided in a timely and sustainable way.
• Where agencies were unable to provide a service to Erik or felt they this required the services of another agency, how was this recorded, communicated & followed up?
• The review will seek to draw on previously published local & national SAR’s where similar harms/risk of harm were identified.
• What are the main issues identified for the way in which organisations work to safeguard and promote the welfare of high-risk individuals?
• Underpinning the above, the direct involvement of Erik’s family so that Erik’s voice can be heard during this review, and the family’s perspective as to how agencies supported Erik both as individual agencies & as a partnership.
• Recommendations will follow CLEAR principles.
  Case for change.
  Learning orientated.
  Evidence based.
  Assigning responsibility.

Report Author

Keith Perkin

Lead Reviewer