Glossary
AFRS – Access and First Response.
CHSCT – Community Health and Social Care Team (Adult Social Care)
COP – Court of Protection.
DCC – Devon County Council.
DPT – Devon Partnership NHS Trust.
IATT – Intensive Assessment and Treatment Team.
OOH – Out of Hours service.
SAR- Safeguarding Adults Review.
SBARD – Used by IATT – Situation, Background, Assessment, Recommendation and Decision form.
TDSAP – Torbay and Devon Safeguarding Adults Partnership.
VIST – Used by Devon and Cornwall Police – Vulnerability Identification Screening Tool
1. Introduction
1.1 This Safeguarding Adults Review (SAR) is commissioned by the Torbay and Devon Safeguarding Adults Partnership (TDSAP) to learn from the circumstances surrounding the death of Stephen in December 2020. Stephen’s body was found at his home on the 17th December 2020. A 42-year-old male and 32-year-old female were subsequently found guilty of his murder and sentenced to minimum prison terms of 20 and 18 years respectively. They are described in press reports being under the influence of both alcohol and heroin when they murdered Stephen. They appear to have known him for a short period of time before murdering him.
The SAR considers five months in Stephen life up to the point of his murder. It explores the following themes:
Were opportunities taken to identify that Stephen was at risk of abuse and/or being abused?
Were opportunities taken and processes robust enough to protect Stephen from abuse?
How was Stephen involved in the decisions and actions taken to protect him from abuse?
How did agencies work together to protect Stephen from abuse?
Evidence for the SAR findings was gathered via IMRs, chronologies, conversations with individual practitioners and a learning event. The SAR was supported by a Panel of involved organisations.
2. Who was Stephen?
2.1 Stephen was a 60-year-old man of white UK heritage who lived alone in a property left to him in Trust after his father died in June 2017. He is described as having a ‘mild to moderate’ learning disability. In court reports he is also referred to as a person with autism, although he had never been diagnosed.
2.2 Stephen is reported to have been proud of owning his own home and of his possessions. Stephen had experienced significant bereavements. He lost his mother, followed by his father going into a nursing home and dying in June 2017. The family dog died around two years before the time considered in this SAR. Stephen kept the possessions of those he loved in the bungalow, he could not bear to let them go. Stephen would not let support workers clean or interfere with his possessions, he did not want items in the house touched or repairs made to the house. Stephen’s toilet was broken, he had numerous electrical items plugged into a chain of leads which created fire risk. Stephen did not want to move away from the bungalow and its memories.
2.3 Stephen was supported by Lifeways Community Care for ten years prior to his death. He was well-known to everyone in the local area who worked at Lifeways, he was chatty and would frequently telephone office staff as well as the helpline. He had the same support workers for many years and viewed some of them as family. As Stephen had no next of kin Devon County Council was appointed as Deputy for his Finances.
2.4 Stephen is described as a friendly and gentle person who wanted desperately to be liked. He felt very lonely. Stephen was heterosexual and saw himself as wanting a girlfriend.
2.5 Stephen could be overfriendly with people. He wanted to please people, to be liked. He invited people he had not met before back to his bungalow, giving his address and personal details to strangers. He was extremely lonely and either because of his feelings of isolation, and/or his struggle to use and weigh the information given to him by his support workers about risks, he placed himself in risky situations.
2.6 Stephen appears to have had a long history of alcohol use which impacted on his daily life. Stephen had not had support to reduce his drinking or to deal with the experiences or emotions that might be leading to increased use. Stephen did not have a great deal of money to spare. If Stephen was very intoxicated with alcohol this was usually because others had supplied it.
3. Summary of events considered by the SAR
3.1 At the beginning of August 2020 Stephen mentioned new ‘friends’ to his support workers. Over the next three weeks his key safe was tampered with and his keys disappeared. Stephen was drinking frequently and heavily with these men. One of Stephen’s support workers visited one of the men and asked him not to call on Stephen. The support worker contacted the Lifeways safeguarding lead for advice and made a safeguarding referral on the 3rd September to Devon County Council (DCC). Lifeways were concerned that Stephen was neglecting himself and was mentally/physically deteriorating. The referral does not mention the possibility of ‘mate crime’ or ‘exploitation’.
3.2 DCC consulted Stephen’s GP and risk rated this referral based on GP information. Lifeways was not contacted, and the referral was risk rated without the further clarifying information they could have given.
3.3 On the 23rd of September Stephen called the police to report a burglary. On attendance Stephen was intoxicated with alcohol and it was hard for officers to establish whether a burglary had taken place or not. Police officers called the local authority out of hours service (OOH) to get some background information about him and also contacted the Devon Partnership Trust (DPT) Access and First Response service (AFRS) requesting street triage. The attending police officer submitted a Vulnerability Indicator Screening Tool (VIST), graded as medium risk, but later upgraded to High Risk after Lifeways gave more information to the police the following day.
3.4 Lifeways made a second safeguarding referral on 24th September. They had not been spoken with about the first referral and DCC had taken no action. The Safeguarding Hub recorded preventative actions that had been taken including the cancellation of Stephen’s card and having his locks changed and a new key safe fitted. Stephen was reported to be extremely anxious and afraid.
3.5 This referral was added to the referral of 3rd September. The risk rating of the previous concern now that new information was added was not reviewed.
3.6 Stephen called the police himself on 24th September to say that someone kept calling his mobile shouting “Stevie” and they were now banging on his door. Officers from CID who were on their way to speak to Stephen about his burglary were allocated this incident. They attended Stephen’s home address and gave him reassurance and advice on this matter.
3.7 On the 25th of September a DCC Court of Protection (CoP) team Case Officer asked to be included in a planned response to Stephen as some of the concerns pertained to financial abuse. Also, on the 25th of September the Lifeways support worker spoke with Stephen’s GP regarding Stephen’s drinking and the burglary. The GP referred Stephen to the Learning Disability Intensive Assessment Treatment Team (IATT). IATT spoke with Stephen and his support worker and completed a Situation, Background, Assessment, Recommendation, Decision form (SBARD) which summarised Stephen’s background and the support workers concerns about him. IATT also made a referral to DCC for an urgent review of Stephen’s care and support needs attaching the SBARD to this.
3.8 On the 26th of September the Police made a safeguarding concern referral to DCC, the third safeguarding referral relating to Stephen in a month. The police were particularly concerned that Stephen had been exploited, his loneliness played into his vulnerability. His house was in ‘very poor condition’ with evidence of hoarding, fire risk, little food but lots of empty bottles of cider. Stephen had been neglecting his own hygiene. The Police added contact details of Stephen’s support worker who the police had spoken with. The Police also referred to Devon Fire and Rescue Service team who requested a Home Safety Visit. The visit did not take place until after Stephen’s death.
3.9 This third safeguarding concern referral was again added to the concern of the 3rd of September. The risk rating on the ‘waiting list’ was not reviewed.
3.10 On the 2nd of October a Safeguarding Enquiry was assigned to the local Community Health and Social Care Team (CHSCT). A CHSCT social worker called to see Stephen on the 9th of October without liaising with Lifeways. Stephen was out. The social worker then contacted Lifeways and met with Stephen, the Lifeways Service Manager and support worker on the 13th of October.
3.11 CHSCT recorded details of the meeting on a Safeguarding Enquiry form denoting that this meeting was part of an enquiry under s42(2) of the Care Act 2014. Stephen was thought to have the capacity to make decisions about how he wished to live. None of the interested organisations, including the CoP team, IATT, the GP or the Police were invited to attend. Lifeways received no further information or contact from DCC following this meeting.
3.12 Lifeways telephoned the GP again on the 28th of October as they were still very concerned about Stephen’s alcohol use. The GP and support worker agreed that they would try to book Stephen in for a review and flu jab and that the GP would talk to CHSCT again.
3.13 Stephen was murdered on the night of 14th December. His body was not found until the 17th of December. He had cancelled his support on the 15th of December directly with the support worker, contrary to Lifeways policy. No-one from Lifeways attended Stephen on the 16th of December.
4. Findings and Learning Points
4.1 Were opportunities taken to identify that Stephen was at risk of abuse and/or being abused?
4.1.1 Lifeways and Devon and Cornwall Police made timely referrals regarding risk to Stephen. IATT picked up these risks in their referral for a care and support needs assessment.
4.1.2 A discussion with the referrer, Lifeways, after their first safeguarding concern referral may have indicated the potential of risk from third parties to Stephen as well as his self-neglect. Early discussion may have also meant that Stephen could be involved at an earlier stage. Lifeways were struggling and a conversation at the information gathering stage might have led to initial advice on the steps they could consider to develop their support to Stephen. Referrers need to know timescales regarding next steps and when to escalate when no further responses are received. Referrers also need to be aware if they have made a referral that does not meet the statutory criteria and to discuss what next steps to take. This will have a beneficial effect on referrers understanding of when to make a safeguarding concern referral. The Safeguarding Hubs are still struggling to keep to the timescales specified in agreed procedures and make timely contact with referrers or progress safeguarding referrals. This is reported to be due to the number of referrals that must be put through the safeguarding process.
Learning Point 1
Conversations with referrers are a vital part of information gathering regarding safeguarding concerns. If continual pressure on a service means that agreed timescales and activities can no longer be adhered to then a review of the service and procedures is indicated. Referrers need to know what the expectations are about each of the ‘four stages’ of safeguarding[1], this can support them to decide if they need to use agreed escalation pathways to maintain their duty of care toward the person they are referring. Feedback to referrers can also increase understanding about when to make a safeguarding concern.
4.1.3 Lifeways already had concerns about Stephen’s interactions with third parties when they made the referral of the 3rd September. They may have decided to include these in the first referral if prompted by consistent references to Mate Crime on the TDSAP website and via the referral guidance.
Learning Point 2
Policy, procedure, and guidance can be difficult for referrers to navigate and need to be aligned to promote consistent awareness of possible forms of abuse. Website materials should be easy to access for a variety of users. “Mate Crime” or exploitation by people considered to be friends, is not presented consistently through all activities on the TDSAP webpages.
4.1.4 Third party abuse was indicated once Stephen had been burgled and further safeguarding concern referrals were made. However, the focus of the Safeguarding Hub and the locality team was still unclear. The referrals ‘seemed similar,’ there was a ‘drift’ away from the possibility of third-party abuse onto self-neglect and Stephen’s environment.
Learning Point 3
Use of consistent risk indicator and assessment tools commonly owned within and outside of DCC will help to focus thinking on potential safeguarding concerns. These tools need to be kept updated to reflect new knowledge or trends.
4.1.5 Practitioners in the Safeguarding Hubs receive and process large volumes of referrals. What impact does this have on their perceptions and decision making about risk? Working at a fast pace can lead to unconscious bias about referrers or about the details of a referral. It can also lead to nuances and unusual risk indicators being missed. The processing of large numbers of safeguarding concerns over a long period of time can lead to a ‘numbing’ of empathy or other aspects of professional curiosity. Supervision which encourages the recognition of unconscious bias and promotes professional curiosity will be helpful, as may be the rotation of teams or regular face to face contact with referrers.
Learning Point 4
We need to pay attention to the specific support and supervision needs of practitioners in adult safeguarding decision- making teams.
4.2 Were opportunities taken and processes robust enough to protect Stephen from abuse?
4.2.1 Lifeways made efforts to protect Stephen from abuse. They made safeguarding referrals and indicated that they were struggling to support Stephen safely in the hours allocated to them. A support worker visited one of the men to try to warn him away from Stephen. Lifeways were very active in trying to create a support network around Stephen and worked with the police, GP and IATT.
Learning Point 5
We need to have working partnerships that respect and listen to the skills, knowledge and experiences of colleagues who work in provider settings. People are left at increased risk if we fail to form these positive relationships.
4.2.2 The organisations involved with Stephen, including the Court of Protection team, indicated willingness to be involved in protecting Stephen. However, they needed coordination from a lead agency to do so robustly. This lead agency should have been the local authority as part of its’ duties under s42(2) of the Care Act 2014. Had there been coordination of the multi-agency efforts to protect Stephen there would have been:
- access to the skill, knowledge and resource of several agencies who could create options for support and protection with Stephen.
- attention to Stephen’s wellbeing, his isolation, finances, grief, health – all with the potential to increase his resilience to further harm.
- agreement on information sharing about the people visiting Stephen.
Multi-agency working may need further promotion in Devon.
Learning Point 6
Enquiries under s42 of the Care Act 2014 can take many forms. It is important to recognise the type of Enquiry needed and to be confident in leading and coordinating a multi-agency approach. Multi-agency approaches bring resourcefulness in creating protective options in complex situations. Guidance and support may be needed with DCC to use this approach as necessary in adult safeguarding.
4.2.3 There was no agreement with Lifeways, the organisation identified as a ‘mitigator’ and ‘monitor’ of risk regarding Stephen, about how they would fulfil these roles. There was no communication with Lifeways from DCC after the meeting of the 13th October 2020.
See Learning Point 5.
4.3 How was Stephen involved in the decisions and actions taken to protect him from abuse?
4.3.1 Stephen did not give consent to the first referral made by Lifeways regarding his self-neglect, this was consistent with the context of the referral as Stephen was not consenting to any form of support whilst his mental and physical health appeared to be deteriorating. In these circumstances a referral without consent can be contemplated.
4.3.2. IATT and the police involved Stephen with the support of Lifeways. CHSCT saw Stephen alone and in the company of his support workers, but appears to have felt that Stephen’s rights had to be protected from the concerns of the support workers. CHSCT had a ‘different view’ from the provider’s perceptions of risk. The CHSCT view was also informed by Stephen’s expressed view of risk. To be person-centred we need to understand the context of a person’s decision making and what may lead them to make decisions others consider unwise. This may or may not be related to a person’s mental capacity. In the enquiry report CHSCT gave a good summary of some of the factors that could create risk for Stephen. But they did not create a relationship with Stephen where the benefits and risks in his situation could be explored. In the absence of multi-agency working CHSCT was unable to create any protective options to be explored with Stephen. Stephen remained afraid and very anxious.
Learning Point 7
Person centred safeguarding is not just about supporting a person to express their views and wishes, but about creating a relationship in which the person is facilitated to explore all the objectives of an enquiry, not only about risk and protection options, but also redress, recovery and resolution.
4.4 How did agencies work together to protect Stephen from abuse?
4.4.1 Without coordination agencies were unable to protect Stephen. After the 13th October information about people going into his house was not shared. Lifeways continued to try to work with Stephen’s GP. The support worker who had been so determined and persistent in attempts to get organisations involved was on long term sick leave. Apart from reminders and advice from his support workers Stephen was left without protection.
See Learning Points 1,5, 6 and 7.
4.5 After Stephen’s death.
After Stephen died the support to the practitioners and managers involved with him varied. Practitioners involved with a person who has experienced a violent death rarely ask for support but may experience negative psychological impacts which lead to a loss of confidence or even leaving the organisation or profession. “Task focused” approaches will not be adequate, organisations need to offer professional de-briefing, reflective group meetings (where possible multi-agency) and individual counselling if needed. Police colleagues will be able to advise on whether on-going investigations will be impeded by any of these activities.
Learning Point 8
Organisations have a duty of care toward their employees. A published offer explaining the supports available, together with attention to the needs of those involved in tragic events, will not only fulfil the organisation’s duty but also contribute to a learning and resilient workforce.
[1] Section 4 at https://www.devonsafeguardingadultspartnership.org.uk/document/multi-agency-safeguarding-adults-guidance-and-procedures/#4-2-the-four-stage-process
5. Recommendations to Torbay and Devon Safeguarding Adults Partnership (recommendations 1-4)
Recommendation 1:
TDSAP is recommended to receive reports back from Devon County Council regarding any changes proposed to TDSAP agreed published policy and practice. Any proposed changes will be agreed with TDSAP partners.
Learning Point 1
Recommendation 2:
TDSAP is recommended to work with a steering group of referrers, including care providers, to improve the accessibility and connectivity of website materials which are a key support for referrers. This can be with the aim of promoting accurate identification of abuse, including “mate crime”, and supporting detailed referrals to the Safeguarding Hubs. Follow up work could also be considered with the TDSAP Community Reference group to ensure that adults and informal carers can easily access referral routes.
Learning Point 2.
Recommendation 3:
TDSAP is recommended to promote positive and respectful partnerships with social care providers in all aspects of its’ work. This can thread through all activities and may be in the form of listening events, joint training, representation on working groups, presentations of preventative work by social care providers to the TDSAP and more.
Learning Point 5.
Recommendation 4:
TDSAP is recommended to promote appropriate support together with individual and/or multi-agency debriefing of staff after a tragic event. This may be done via a) best practice advice on the TDSAP website and b) integrating an expectation of post tragic event debriefing and support into SAR processes.
Learning Point 8 and recommendation 6.7 below.
6. Recommendations to partner organisations
Recommendations 5-8 may contribute to the Rapid Improvement Plan currently being undertaken by DCC. The Plan may well have concluded before the SAR is received by TDSAP, but it is hoped that these recommendations may inform current and potentially future thinking.
Torbay Council and Torbay and South Devon NHS Foundation Trust may also find recommendations 5-10 useful when considering Torbay procedures and practice in safeguarding adults.
Recommendation 5:
Devon County Council are recommended to review the service offered by the Safeguarding Hubs in respect of whether there are types of referrals that do not need to be progressed via s42(1) and whether the timescales stated in policy and procedures are achievable. Any changes needed to guidance will need to be reported back to the TDSAP. Consider auditing to ensure that the policy is being followed, in particular the need to respond to referrers and to consider risks within each referral discretely.
Learning Point 1.
Recommendation 6:
Devon County Council are recommended to consider how to mitigate the impact of long-term working in the Safeguarding Hubs on decision-making. This may be through work flow and supervision practices which encourage professional curiosity, rotation into front line services or regular face to face contact with referrers and front-line practitioners.
Learning Point 4
Recommendation 7:
Devon County Council are recommended to continue in their work to create consistent risk indicator and assessment tools, and also to develop mechanisms to keep these tools updated and to publish these to raise awareness and understanding in partner organisations.
Learning Point 3
Recommendation 8:
Devon County Council are recommended to undertake activities to promote positive and respectful working relationships with social care providers in all teams, including the Safeguarding Hubs and locality teams. These may range from reflections on unconscious bias to spending time with provider teams to increase mutual understanding.
Learning Point 5.
Recommendation 9:
Devon County Council are recommended to identify and address current barriers to using coordinated multi-agency approaches as necessary in enquiry work and protection planning. The TDSAP Escalation Protocol can be used should there be barriers around partner participation.
Learning Point 6
Recommendation 10:
Devon County Council are recommended to review and revise relationship-based person- centred safeguarding approaches across the range of Enquiry objectives and within the context, when necessary, of multi-agency working.
Learning Point 7.
Recommendation 11:
All organisations are recommended to create contingency plans for employee support after a tragic or other high impact event.
Learning Point 8.