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SAR Stephen



AFRS – Access and First Response.

CHSCT – Community Health and Social Care Team (Adult Social Care)

CID – Criminal Investigation Department.

DCC – Devon County Council.

DPT – Devon Partnership NHS Trust.

IATT – Intensive Assessment and Treatment Team.

LC – the male found guilty of Stephen’s murder.

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. 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.

1.2  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 regarding his murder he is also referred to as a person with autism, although he had never been diagnosed. Stephen is reported to have been proud of owning his own home and of his possessions, including his Elvis memorabilia. He kept hold of everything relating to his life, old motorbikes, and his parents’ possessions together with items related to the family dog who died a year or so after his father. 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.

1.3  This review is conducted in accordance with section 44 of the Care Act 2014 and the TDSAP Safeguarding Adults Board Procedures. Stephen’s case was referred to the TDSAP in January 2021 by Devon and Cornwall Police. His murder met the criteria for a SAR as he had care and support needs, had died as a result of abuse and there was reasonable cause for concern about how organisations had worked together to safeguard him. The SAR was initially delayed whilst the criminal trial was in progress, the perpetrators were found guilty in May 2022. Organisations submitted reports to the SAR by the end of November 2022. A delay between submission of reports and progressing the SAR is attributed to the capacity of the TDSAP Business unit and that of the lead reviewer. In the interim the organisations involved initiated immediate actions based on the learning. These are captured in section 8.

Under section 44 of the Care Act 2014 a Safeguarding Adults Board must arrange for there to be 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 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 the adult has died,
  • and the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to

(a) identifying the lessons to be learnt from the adult’s case, and

(b) applying those lessons to future cases.

2. Terms of Reference

The full terms of reference can be found in appendix 1 at the end of this Report.

2.1 The timeframe of the SAR is:  1st August 2020 until 17th December 2020.

Rationale:  The timeframe begins just prior to reports being made of third parties stealing from and/or potentially exploiting Stephen. It ends when his body was discovered.

2.2 Organisations who have participated in the review.

Devon and Cornwall Police.

Devon County Council.

Devon Partnership Trust.

Lifeways Community Care.

Livewell SouthWest.

Wembury Surgery.

2.3 The specific areas of focus for the SAR are:

  • 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?

We will also learn from good practices evidenced in the review, exploring how we can develop and disseminate these.

3. Methodology

The Review had two parts:

Part 1 Analysis of written evidence to identify themes for further exploration.  Conversations with practitioners and managers for clarification.

Part 2 A learning event with practitioners involved in Stephen’s care and their managers.

An overview report was produced following the learning event with findings and recommendations for the TDSAP.

4. Family involvement

Stephen had no immediate family or friends. He was adopted by his parents who had died before the time frame considered by the SAR. The Review has attempted to find any family through contact with the solicitor responsible for the Probate of Stephen’s estate. There are distant family members, but they did not know Stephen during his adult life.

5. Other processes

The two individuals responsible for Stephen’s death have been found guilty of murder and were sentenced in May 2022 to minimum prison terms of 20 and 18 years respectively. An Inquest has not yet been held into Stephen’s death.

6. Relevant history prior to the time in scope

6.1 Stephen was supported by Lifeways Community Care for ten years prior to his death.  At the time under consideration Lifeways was commissioned to support him for up to 23 hours a week which could be spread over seven days. It is reported that the number of commissioned support hours had reduced sometime prior to the pandemic. Stephen was well known to everyone at Lifeways, including office staff, on-call managers, and the support workers. He had the same core support workers for many years and got on particularly well with support worker 1. Support worker 2 recalls that it felt that Stephen looked up to him as an older sibling.  Stephen is reported to have been a very ‘private person’ and it was hard to get him to talk about himself despite the longevity and consistency of his relationships with support workers. He wanted to be liked, but also feared that what he had would be taken from him, that his opinion did not count. Others have described him as small in stature, not confident, with humble body language and uncertain of his way in the world.

Stephen usually requested to go out with his support workers, he liked to go shopping and was a very friendly person who enjoyed speaking to people in the community. He had previously worked as a volunteer for the British Red Cross and enjoyed visiting car boot sales, walks to the local beach and going out on a boat belonging to a Lifeways support worker. He had recently purchased a guitar. As Stephen had no next of kin Devon County Council was appointed as Deputy for his Finances.

6.2 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. He slept in his father’s hospital bed. 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. He liked to put up Christmas decorations all year round which increased the fire risk. Stephen did not want to move away from the bungalow and its memories.

6.3 Stephen appears to have had a long history of alcohol use which impacted on his daily life. Sixteen years previously he had drink driving offences committed when riding a motorbike. His GP reports that alcohol ‘had always been a concern’ and that he gave advice at each of Stephen’s annual health checks. Those who knew Stephen noted that his alcohol use increased after his father died, with the implementation of COVID restrictions which impacted on his daily routines and later after the burglary of September 2020. 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. Lifeways managers report approaching his Deputy to see if the weekly amount could be increased but this was not possible within the benefits he received. If Stephen was very intoxicated with alcohol this was usually because others had supplied it. In the weeks leading up to the time in scope support worker 1 was concerned about Stephen’s drinking and lack of self-care. His appetite had decreased, and he did not wash, he was losing weight. He was forgetful and at times seemed confused.

6.4 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 continued to place himself in risky situations. His GP reports that he was ‘well known’; in the village and thought that this could have increased the possibility of his being targeted. Stephen was persistent in his approaches to adult women. We do not know if this led to a reputation in his village which may have been known by the group of men he had begun to associate with.

7. Key Events and Analysis from the time covered by the SAR

7.1 Key Episode 1: 1st August 2020 - 19th September 2020

7.1.1 On the 1st of August 2020 Stephen mentioned a new friend to his support worker. The man lived over the shop which Stephen regularly used and is likely to be LC. Over the next three weeks Stephen’s key safe was tampered with and his keys disappeared. He continued to see LC and was noted by his support workers to be drinking frequently, on two occasions admitting to being ‘very drunk’ whilst out with his ‘friends’. Support worker 1 is reported to have visited LC and introduced herself as Stephen’s support worker. She asked him not to call on Stephen in the future. Stephen’s support workers contacted the Lifeways Safeguarding lead for advice.

7.1.2 Stephen struggled to understand other people’s motivations and the boundaries around friendships. A local woman offered him a meal and gave him her telephone number. Stephen made 89 telephone calls to her; none were offensive but were completely overwhelming for her.  She reported the matter to the police on the 1st September as Stephen had not respected her request for him to stop but ‘told everyone’ that they were girlfriend and boyfriend. On the 6th of September Stephen was seen by a police officer in relation to these telephone calls. He was supported by Lifeways during the conversation at his home and given words of advice, the report was filed as No Further Action. Stephen is reported to have been ‘devastated’ when this contact ended.

7.1.3 On the 3rd of September the Lifeways Service manager made a safeguarding concern referral to Devon County Council. This appears to have been in the form of an email. Lifeways listed their concerns about Stephen’s situation and stated that they were making the referral at that time because Stephen would not see his GP about increasing health concerns. A summary of concerns as reported was:

1.    Stephen was neglecting himself by not washing or changing his clothes. He was wearing many layers of clothing and was hot but would not take any layer off.

2.    Stephen was buying alcohol on a daily basis; his support workers were encouraging him to purchase the lower alcohol content products but were concerned that he was alcohol dependent.

3.    Stephen appeared more confused, about days and times, forgetting who staff were and refusing others who were long standing staff members, cancelling his support but on the day calling to see where it was as he needed his daily money. He called the Lifeways on call service repeatedly, ‘most of the time’ whilst drunk.

4.    Lifeways believed that Stephen was deteriorating physically and mentally.

5.    Stephen had said that he had a homeless man living with him, but Lifeways found no evidence of this, he also said that his neighbour was sexually harassing him but not to tell anyone.

6.    Lifeways were concerned that Stephen was mentally and physically deteriorating. Stephen did not share this view and became both anxious and angry when asked about these matters. He did not wish to see his GP. Lifeways had therefore referred these concerns to DCC without Stephen’s consent.

7.1.4 In DCC safeguarding concerns are risk rated in the Safeguarding Hubs on receipt. For this referral information was gathered from Stephen’s GP the same day who said that he had no specific concerns about Stephen and usually saw him at this annual review where ‘nothing has changed’. The referrer, Lifeways, was not contacted and the referral was risk rated without the further clarifying information they could have given. Lifeways was contacted about this and subsequent referrals on the 1st October, almost a month later.

7.1.5 The referral was risk rated as ‘medium’. This rating meant that the referral should be opened by a member of the Safeguarding Hub for further information gathering, which may have included a conversation with the referrer, within 48 hours. This did not happen.

7.1.6 On the 12th of September Stephen mentioned another new friend, ‘A’ to his Lifeways support worker, two days later he said that LC no longer wanted to be friends with him, but they later went out together for a bacon bap. Stephen was then worried that ‘A’ no longer wanted to be his friend and telephoned him numerous times.

7.2 Analysis

7.2.1 Good practices

Lifeways made a safeguarding concern referral to the local authority when they unable to take problem solving efforts further themselves but identified risks to Stephen’s wellbeing. They did so without Stephen’s consent, a step that can be taken if there is concern about a person’s ‘vital’ interests [1]. We must remember that this first referral is not about risks from third parties to Stephen, but the risks created by Stephen struggling to care for himself or visit his GP for further support. In retrospect we may see these behaviours as indicators of other pressures on Stephen but at the time this was not apparent to practitioners closest to him. Always ‘private’, Stephen had become ‘secretive’, and Lifeways were not able to prevent a deterioration in his wellbeing.

Devon and Cornwall Police observed the advice on Stephen’s police records that his support workers needed to be included in communicating with him because of his difficulties in understanding and communicating with others.

7.2.2 Areas for development.

There were great pressures on the Devon Safeguarding Hubs during this first year of the COVID pandemic. Whilst safeguarding referrals dropped markedly during the first two months of lockdown (23 March – 30th May 2020) by June 2020 referrals had exceeded normal levels in all English local authorities[2].  During the time around September 2020 the South Safeguarding Hub, like other areas in the UK, had a higher level of self -neglect referrals[3].  Participants in the SAR report that the Safeguarding Hubs are still extremely busy. A ‘waiting list’ system operates where concerns are risk rated on receipt and risk reviewed after further information gathering. In Stephen’s case this further risk review did not happen when new information was received.

SAR activities have also explored other themes regarding practice in the South Safeguarding Hub and the systems around the Hub, both at the time referrals were made about Stephen and subsequently.

Theme 1: Understanding the role of the local authority and purpose of the Safeguarding Hub.

In the Learning Event some participants expressed the view that the Hubs make a decision as to whether something was ’safeguarding or not’. There was a worry about people outside of the local authority making decisions for which they would be held accountable and that generally it was safer to report everything and let the local authority decide.

How does this perception impact on the volume of work in the Safeguarding Hub? The local authority reports high levels of referrals that are not safeguarding concerns which it is obliged to put through the process of decision making based on the three statutory criteria[4]. The local authority may be collecting information for other purposes, for example quality assurance or longitudinal analysis of a premises or organisation. But this information does not need to be put through a safeguarding route.  Overloading the Safeguarding Hubs creates a risk that situations that require an urgent preventative or reactive response can be missed.

The Hub volume of work is managed through an electronic system in which practitioners input types of abuse, rate risk, review risk, allocate onward etc. Dixon (2023) describes a blunting of compassion and empathy which can lead to people becoming abstract sets of colour codes[5].  This can be mitigated by practitioners having contact with the people themselves and/or the referrers, and by being rotated between decision-making teams and front-line practice.

Theme 2: Professional curiosity when information gathering: why refer now?

High volumes of referrals that may or may not be “safeguarding” can also impede understanding of “why refer now?” Whilst some referrers may feel they should refer for a decision as to ‘whether it is safeguarding’, Lifeways were referring Stephen because they did not know what to do next, they needed advice and guidance and believed that Stephen was at risk of harm from his own behaviour. He was growing thin, he appeared both mentally and physically unwell. Although one of the mitigating factors in the Hub’s initial risk assessment was the presence of Lifeways, a close reading of the referral from Lifeways would have explained that they were not able to support Stephen’s wellbeing and needed advice on what to do. These types of referrals need a response, whether from the Safeguarding Hub or relevant locality team.

Theme 3 Professional curiosity when information gathering: information gathering with referrers.

The Safeguarding Hub did not contact Lifeways to discuss the referral but instead contacted Stephen’s GP who did not know him well and had not seen him for some time. Discussing the referral with Lifeways would have enabled:

  • Exploration of what else was happening in Stephen’s life. Lifeways had not recorded their concerns about the people Stephen was associating with, the missing keys from his key safe or his vulnerability to others. These elements could have been teased out in a conversation and would have informed an accurate risk assessment. The potential reasons for Stephen’s behaviour could have also been explored, why was he wearing layers of clothing?  His support workers believe this was to make himself look bulkier, he was losing weight and may also have felt under threat from bigger and stronger men. How much was he drinking? Was alcohol responsible for his deteriorating health or something else? Stress from his interactions with this group of men? Loneliness? Grief?
  • Involving Stephen in information gathering. Devon and Cornwall Police and the Intensive Assessment and Treatment Team (IATT – see section 7.3.9) were able to approach Stephen through his trusted support workers. The Safeguarding Hub may have also been able to involve Stephen at this early stage through contact with his support workers.
  • Early advice and support for the Provider to enable them to find other ways to work with Stephen whilst the referral was being allocated.

At the time of writing the Devon Safeguarding Hubs are still not able to consistently respond to referrers according to the approach or timescales set out in the agreed multi-agency guidance and procedures, i.e., “Concerns triaged by the Local Authority, outcomes decided, and feedback provided within 2 working days[6]. Those procedures also stipulate that “Keeping the person who raised the concern informed is an essential requirement under these policies and procedures. Feedback must be provided to all those raising concerns as this provides assurance that action has been taken whether under adult safeguarding or not. ..Organisations raising concerns may want to challenge or discuss decisions and need to be updated on what action has been taken”.[7]

It may be that it is no longer possible to retain the timescales and approaches as specified in agree multi-agency guidance. This should result in guidance being reviewed.

What do referrers need to enact their duty of care?

Making a safeguarding concern does not remove the referrer’s duty of care toward the person. We will see in section 7.3 that Lifeways continued to try to enact that duty of care in other ways. However, in order to understand what to expect after making a safeguarding concern referral and when to escalate using the agreed Devon Safeguarding Adults Escalation protocol[8], referrers need information.  There is copious information on the TSAP website, but it is hard to find and not consistently reflected in the guidance on the referral process. Referrers are uncertain as to timeframes. Although the multi-agency procedures specify a timescale the referral guidance has no timescales or mention of further contact.[9]

Referrers contributing to the SAR explain that they may have some initial contact but

“A significant problem is still, after initial contact, going weeks without hearing anything and not knowing”.  It may also be useful for a referrer to know when and how to escalate concerns where risk and harm are on-going.

Whilst there is good guidance on “mate crime” under one section of the TDSAP website [10] this category of abuse does not appear in the checklist in the on-line referral form. In addition, ‘mate crime’ is listed on the ‘exploitation’ tab on the website, not under ‘abuse’. The consistent inclusion of mate crime as a form of abuse will confirm that such concerns are a safeguarding matter.

[3] Ibid. LGA (2020)
[4] Care Act 2014 section 42 – find at
[5] Dixon, J (2023)  “Adult Safeguarding Observed: How Social Workers Assess and Manage Risk and Uncertainty” Policy Press: Bristol. Page 68.
[7] Ibid.
[8] (2021)
[9] and
[10] and

7.3 Key Episode 2: 23rd September to 2nd October

7.3.1 On the 23rd of September Stephen called the police around midnight to report the burglary of a TV and Karaoke machine. When the police attended Stephen was intoxicated with alcohol and it was hard 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. Information was shared regarding Stephen’s learning disability, his previous recorded risk history, known alcohol misuse and previous history regarding a possible, but queried, delusional state. AFRS advised that they could conduct a triage of Stephen’s mental state, but this would not be robust if Stephen were intoxicated. DPT sent a letter to Stephen’s GP regarding this contact. 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.

7.3.2 Lifeways made a second safeguarding referral on 24th September. The Safeguarding Hub recorded that Stephen was extremely drunk during the burglary incident and the subsequent police visit. The specific events of what happened were vague and were evolving as Stephen’s memories came back to him. Missing items included Stephen’s TV, cash, and debit card. Preventative actions included 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.

7.3.3 This referral was added to the referral of 3rd September. DCC procedures stipulate that a separate safeguarding concern should be generated as this was a new safeguarding concern relating to possible exploitation. The risk rating of the previous concern now that new information was added was not reviewed. It is likely that it remained ‘Amber’.  The Safeguarding Hub have commented that the new information added to the first referral ‘seemed similar’ but was not properly thought through.

7.3.4 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.

7.3.5 On the 25th of September a DCC Court of Protection team Case Officer emailed the locality team who knew Stephen to bring their attention to the new Safeguarding Concern. The team wanted to be included in the planned response as some of the concerns pertained to financial abuse.

7.3.6 On the 25th of September Lifeways support worker 1 spoke with Stephen’s GP regarding concerns about Stephen’s drinking and the burglary. The GP then spoke with the DPT Learning Disability team and subsequently referred Stephen to the Learning Disability Intensive Assessment Treatment Team (IATT).

7.3.7 On the 26th of September the Police made a safeguarding concern referral to DCC, the third safeguarding referral relating to Stephen in a month.

I would like to formally refer Steven (sic) …to adult social care. I spoke to Steven in the company of his carer today and he has given consent for a referral. I am investigating a burglary – the circumstances are not totally clear, but it appears on 23rd September that Steven has been befriended by a male and invited them back to his house for a drink. At some point Steven has been forced into the bathroom while this male and another male have stolen items from his address including cash, TV’s, mobile phones and a camcorder. Owing to Steven’s difficulties in communication and recollection it has been very difficult to get a full picture of what has happened. Detectives visiting the home have the following concerns in relation to Steven:

  • He is placing himself in vulnerable positions and as a result has been exploited
  • He kept repeating how lonely he was – again this plays into his vulnerability
  • The house was in very poor condition – evidence of hoarding of possessions, certain rooms being largely inaccessible owing to amounts of stuff piled up, this is potential fire risk when given the many items of electrical equipment/Christmas lights, karaoke machines etc. Steve has plugged in.
  • The house was dirty and there was a strong smell of urine throughout
  • There did not appear to be much food in the house – Steve was unkempt in appearance and seemed to be neglecting his personal hygiene i.e. greasy unkempt long hair and dirty fingernails.
  • Steven’s alcohol consumption appears to be an issue – lots of empty bottles of white lighting cider present, on the evening when the burglary happened he appeared to attending officers to be heavily intoxicated which again increases his vulnerability.

7.3.8 The High Priority VIST was added to this referral together with the contact details of support worker 1 who the police had been in contact with. The VIST was also sent to a Devon Fire and Rescue Service team who requested a Home Safety Visit. The visit did not take place until after Stephen’s death.

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.

7.3.9 The Intensive Assessment and Treatment Team (IATT) received a referral from Stephen’s GP on the 30th of September explaining Stephen’s circumstances and asking if they could help with his alcohol use. By the 1st of October IATT had contacted Stephens GP to ask for historical information and had spoken with support worker 1 with Stephen present and contributing to the discussion. Support worker 1 was particularly worried that she had made a safeguarding concern referral but it had ‘not gone anywhere’. IATT said that they would follow this up which they subsequently did.  IATT completed a Situation, Background, Assessment, Recommendation, Decision form (SBARD) which summarised Stephen’s background and the support workers concerns about him, including,

  • Stephen had been befriended by a man called A recently, (who appears to have a key to Stephen’s home) last Thursday A invited another male into Stephen’s home whilst he was intoxicated- Stephen was locked in the bathroom and they continued to burgle Stephen whilst he was locked in there- Stephen was unable to identify the other male. Police are investigating and all locks have been changed in his home, Stephen is reportedly feeling very vulnerable at this time and drinking more alcohol. Stephen is an extremely vulnerable adult; specifically when he’s under the influence of alcohol.
  • Support worker 1 feels Stephen’s needs are not being met with the limited hours allocated to him, she feels that if Stephen was engaged in more meaningful occupation and had more support hours, he would not feel the need to consume alcohol.

7.3.10 IATT also made a referral to DCC for an urgent review of Stephen’s care and support needs. The SBARD was attached to this. IATT report being very concerned about Stephen being locked in his bathroom and felt that this was a concerning indicator of ‘cuckooing’ and/or ‘Mate Crime’[11]  IATT intended to make ‘reasonable adjustments’ to facilitate Stephen using services to address his alcohol use or other aspects of his wellbeing.  However, they also felt that this should be part of a safeguarding response, Stephen needed to be in a stable position with good support before any work could be done regarding his drinking behaviour.

7.3.11 On the 1st of October the South Safeguarding Hub telephoned Lifeways and discussed the information provided by IATT and support worker 1.

7.3.12 On 2nd October the Lifeways Service Manager called the solicitor who acted as Trustee for Stephen’s property, they were exploring Stephen’s options should he decide to move to alternative accommodation. Their thinking was that supported housing might alleviate Stephen’s feelings of loneliness and provide a slightly more secure environment.


7.4 Analysis

7.4.1 Good practice.

This key episode contains a good deal of responsive multi-agency partnership working. On the night of the burglary attending officers took steps to find out as much as possible about Stephen and what needs he might have.

The referral and VIST from the police were detailed and contained clear statements about Stephen’s situation. This was informed by their own observations and in discussion with Stephen’s support worker.

The referral from Lifeways was also timely. Lifeways not only took immediate protection actions but also contacted Stephen’s GP to try to progress their concerns about Stephen’s alcohol use and health.

IATT were aware of the indicators of possible cuckooing /mate crime and undertook a detailed and timely assessment of Stephen’s situation with Stephen and his support worker.  They also made a referral for a care and support needs assessment, followed up on Lifeways original concern referral to the Safeguarding Hub and offered to be part of any ‘planned response’.

Lifeways were in touch with the police, GP and IATT regarding Stephen’s wellbeing and protection. The CoP team were aware and wanted to be involved. The helpful organisations around Stephen were willing to work together in efforts to work with Stephen to improve his situation and protect him from further exploitation. The referrals they made did result in Stephen’s case being sent forward for allocation within six – eight working days of the third and second referral. These helpful organisations needed coordination from a lead agency. This theme is explored in section 7.6.

7.4.2 Areas for development

One form of abuse may lead us to be curious about what else might be happening in the situation.  On quick reading by a pressurised practitioner in the Safeguarding Hub the concerns reported during late September ‘seemed similar’ to those of the 3rd September.  Once a person is defined as ‘self-neglecting’ is the possibility of third-party abuse still considered?  A recent SAR has highlighted the need to look beyond initial thoughts about self-neglect[12] and think about what else might be happening in the person’s life and whether others are exploiting the person’s specific vulnerabilities. DCC appear aware of this and intend to include these risk indicators and the need for professional curiosity around them in new guidance as explained in section 8.

[12] Rotherham SAB (2021) SAR The Painter and his Son

7.5 Key Episode 3: 5th October to 17th December

7.5.1 On the 2nd of October a Safeguarding Enquiry was assigned to the local Community Health and Social Care Team (CHSCT). It was sent in a ‘raw state’ – which appears to mean that the referral information was listed rather than containing any analysis of gathered information or of how the section 42.1 criteria were met. In addition, the form had not been completed correctly by the South Safeguarding Hub, a second form to indicate that an Enquiry was needed was not visible.

7.5.2 On the 5th of October IATT emailed the CHSCT team manager requesting an update regarding both the safeguarding and care and support needs assessment referrals. IATT asked to be invited to any meetings arranged by CHSCT. The team manager emailed back to confirm that they would be undertaking a review with Stephen as a matter of urgency. They would be pulling a safeguarding strategy meeting together once contact had been made with Stephen and would ensure that IATT were notified of this.

7.5.3 Also on the 5th of October the Police noted that two local women were believed to be spending time with Stephen at his home address. Neither were subsequently involved in Stephen’s death. This information does not appear to have been shared with other organisations involved.

7.5.4 Lifeways noted that Stephen was still very exercised about the burglary and his drinking had increased as he struggled to cope with his feelings. On the 8th of October he used the Lifeways support line to say he was getting texts and calls from ‘T’ who Stephen said was one of the people who stole from him. He said that he had told ‘T’ that he was a thief and not to come round, but later mentioned that he was getting weird calls from ‘T’ at night. On the 9th of October Stephen called the support line again to discuss the ‘scary burglary’ and talked about someone called ‘D’ who was involved and would ‘chin him’.

7.5.5. 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 arranged to meet Stephen and a support worker on the 13th of October. This meeting took place with Stephen, the Lifeways Service Manager and support worker 3 on the 13th of October. By this time support worker 1 was on extended leave.

7.5.6 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. Risks were summarised on the form as:

“Stephen is a vulnerable person made more vulnerable by his consumption of cider every evening. He is an isolated person who naturally enjoys some contact with people apart from his carers/support workers. It appears that recently he has formed links with a small group of men who he has seen around for some time and after drinking together these men committed the crime outlined above. Stephen has discussed the incident which has made him anxious and worried as something he will not allow to happen again. However, his ability to avoid such events is questionable. He is keen to point out that he has changed his locks and has no contact with the individuals concerned.

My analysis is that given the lock change, involvement of the police, the stress it has caused him, and the involvement of Lifeways on a daily basis, provide Stephen with adequate immediate protective measures. As Stephen lives alone and likes going out for walks every day, and as he likes to drink most evenings, it is impossible to completely remove the risk of him having more contact with the people (two of whom it appears live nearby) who stole his stuff. However, there are no additional safeguarding measures to be made at the moment, and Lifeways who do see Stephen daily are best placed to monitor the situation.”

7.5.7 Lifeways were concerned about how Stephen’s capacity to make decisions to protect himself was ascertained. CHSCT had a verbal discussion with him during the meeting about what he would do if threatened and decided that Stephen had capacity to make decisions about how he wished to live.

Lifeways received no further information or contact from DCC following this meeting.

7.5.8 The CHSCT social worker has acknowledged that they had a different view of the risks in Stephen’s life from the care provider. The social worker did assess that there was a fire risk and also decided to speak with Stephen’s GP regarding Stephens’ drinking and weight loss. It took some time for the GP and social worker to speak, the social worker was not available when the GP rang. The conversation finally took place on the 30th of October and did not change the social worker’s view of the risk to Stephen. The GP recorded that they were told that Stephen ‘had a good care package in place, alcohol had always been an issue and (CHSCT) was satisfied that no further involvement was required.”

7.5.9 On the 26th of October IATT emailed the CHSCT team manager requesting an update as to when a safeguarding meeting would be held. IATT thought that there was either a delay to the strategy meeting being called, or it was held without them being involved.

7.5.10 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 try the social worker again which they did successfully as noted above.

7.5.11 On the 17th of November IATT emailed the GP, copying in the CHSCT team manager, to reject the GP referral. IATT felt that Stephen’s vulnerability, alcohol consumption and physical health could only be assessed and supported through the safeguarding process, and it would not be appropriate to offer any further input until the safeguarding process had been undertaken.

7.5.12 The burglary was being investigated by police detective officers. The Police report that the investigation was not timely, and there was no contact with Stephen in the five weeks leading to his death. Consideration was not given to a video interview with Stephen where he could be supported by a Lifeways support worker or intermediary.  There is no suggestion that the burglary had any bearing on Stephen’s death however the police author notes that “as a victim of crime Stephen was let down by Devon and Cornwall Police and the service, he was given could have been better”.   These matters have been addressed with the officers concerned who deviated from Force policy and procedure in these matters.

7.5.13 On the 5th of December Stephen attended the GP surgery with his Lifeways support worker for his flu vaccination. On the 11th of December Lifeways support workers 2 and 3 discussed information given to support worker 3 by a neighbour who saw a man and a woman going into Stephen’s bungalow. Stephen denied this was true but was reminded not to let anyone into his property.  Support worker 2 thought that his colleague was going to report this to the police, but this did not happen.

7.5.14 On the 14th of December support worker 2 completed his shift with Stephen at 3pm with ‘no issues’ to report. Stephen was murdered on the night of 14th December, forensic reports described in the press ascertained that he would have lived only thirty minutes or so after the attack on him. Stephen’s body was not found until the 17th of December. He had cancelled his support on the 15th of December during the previous weekend directly with support worker 2, contrary to Lifeways policy. No-one from Lifeways attended Stephen on the 16th of December.

7.6 Analysis

7.6.1 What went well.

The GP and Lifeways continued to work together whilst CHSCT and the GP had follow up contact. Lifeways facilitated and supported CHSCT’s meeting with Stephen. IATT continued to follow up and ask CHSCT for updates on potential work with Stephen.  CHSCT saw Stephen at his home, and continued to see people appropriate to vulnerability and need after risk assessment during the 2020 COVID period.

7.6.2 Areas for development.

As noted in section 7.4.1 above, the organisations around Stephen were concerned and already working with Lifeways who had begun to create a partnership response around Stephen by working with the GP, Police and IATT.  These organisations would have been skilled and valuable partners in any multi-agency discussion about options that may have supported Stephen and reduced the risks he faced. The Court of Protection (CoP) team would also have been valuable partners in considering Stephen’s material situation and options that may have improved this aspect of his wellbeing.

A multi-agency meeting with neighbourhood police colleagues who had local knowledge, Lifeways who knew Stephen well, IATT to assist Stephen’s access to supportive services, the CoP team and potentially Stephens GP, had a good chance of identifying creative options to explore with Stephen and to work with him to overcome any challenge he was experiencing in contemplating risk and change.  A multi-agency meeting could have also set up information sharing agreements about with/by whom and when information should be shared about individuals coming into Stephen’s home. Why did no such meeting take place?

Participants at the Learning Event remarked that Devon had moved away from formal meetings and have some great examples of Making Safeguarding Personal.  Has an emphasis on ascertaining the person’s views and preferred outcomes detracted from the need, when necessary, to coordinate a multiagency response during enquiry and protection/recovery planning?  Others thought that pressures on partner organisations made it hard to convene multi-agency meetings. In Stephen’s case organisations were already involved or had indicated a wish to be involved (IATT and the CoP team).

TDSAP policy and procedures have an emphasis on involving the person and not on co-operating with other agencies. Whilst there is reference to the duty to cooperate[13] there is no published guidance on when to coordinate a multiagency enquiry and what expectations are. This may exist internally to DCC, but how are service users, partners, and referrers to know what to expect?

Are practitioners in DCC and partner organisations confident in how to convene and manage multi-agency responses? Is there sufficient support and focus to do so? During the first year of the COVID pandemic the CHSCT team, like other teams across the UK, were working from home. The team manager arranged formal team meetings and ‘catch-ups’ twice a week where team members could share cases, struggles etc. The team would also communicate via What’s App and team chats between meetings. The CHSCT social worker spoke with a colleague who had previously worked with Stephen, they talked about risk and choice. The team was distracted at this time however, they were all involved with the closure of a five bedded care home.  This was an intense piece of work which was pre-occupying the team including the social worker and may have taken focus away from other work.

Lifeways report their frustration at “not being listened to” regarding the risks around Stephen, his self -neglect and the people he was associating with. National workshops[14] held in 2019 explored some of the challenges around multi-agency working in adult safeguarding, in terms of relationships with social care providers there was,

“in particular a lack of respect for social care providers. These relationships can be typified by a lack of trust and ‘blame culture’. There is no parity of esteem between agencies.”


“A lack of respect can extend to a failure to feedback decisions about concerns…preventative and responsive partnerships cannot thrive without dialogue.”

These attitudes can be underpinned by an unconscious bias toward what provider staff are observing and reporting. These colleagues may see the person on a daily basis and/or have known the person for many years. The social worker ‘did not agree’ with the risks seen by the provider and saw themselves as supporting Stephen’s right to make his own life choices in the context of an overly anxious provider. There appears to be limited dialogue between CHSCT and Lifeways before or after the visit of October 13th. This dialogue may have established that the provider staff also wished to support Stephen’s right to make his own life choices but were reporting that they were unable to do so safely and had real concerns about the risks Stephen was taking on a daily basis and the potential factors influencing his choices. Lifeways were left without guidance about what ‘monitoring the situation’ constituted. What to report and to whom? Lifeways had been ‘monitoring’ for some months and remained concerned about the deterioration in Stephen’s mental and physical health.

Because of the perception of the provider’s concerns CHSCT have reflected that the focus of the work drifted from the safeguarding concerns into concern about Stephen’s wellbeing, in particular his hoarding of items in the house. There was also a belief that as Lifeways were commissioned to provide up to four hours support per day they needed to work with Stephen using more effective approach regarding his self-neglect. This was not conveyed to Lifeways however who had already reported that they were struggling to work with Stephen within the hours commissioned. CHSCT did understand the factors that increased the risk of Stephen’s exploitation, as described in 7.5.6, but had not agreed any supportive or monitoring plan with Lifeways for follow up on any continual impact those factors might have. In the absence of multi-agency problem solving CHSCT may well have found it hard to come up with any options to explore with Stephen.

CHSCT believed that they had taken a person -centred approach to the concerns around Stephen. The social worker presumed that Stephen had the mental capacity to make decisions about how he lived and who he associated with, but with caveats about the factors that might make it hard for him to keep away from the men who shut him in his bathroom and stole from him.  The hope was that now Stephen had been scared by the burglary and could see the risk from some of his social contacts, he would keep away from them and a change of locks and police interest would facilitate this. This belief was informed by an interview with Stephen who is reported to be able to discuss his situation fluently. Lifeways concern was that Stephen’s verbal fluency disguised his struggle to use and weigh information in order to make decisions about his environment, health and safe relationships.  Whether as part of an assessment of mental capacity or not, the influences on Stephen’s decision-making needed to be explored and observed. Was his holding on to items related to his grief and loneliness? How could he be supported with these overwhelming emotions? Was he afraid of the men he associated with? What attracted him to their company? What impact did their company have on his need to wear layers of clothing or his financial situation? The safeguarding enquiry recorded that Stephen’s “ability to avoid such events is questionable” but that there were “no further safeguarding measures to be taken”.  A multi-agency meeting including police colleagues who may have been able to share information about the nature of some of the people Stephen was seeing, as well as inform an agreed protection plan, would have been helpful. Finally, the emotional impact of the burglary on Stephen was not addressed as stipulated in the objectives required in any Enquiry.

A narrative from the South Safeguarding Hub on the risks detailed in the referrals may have helped to focus the Enquiry. This narrative could be supported by a consistent risk assessment tool with attention paid to likelihood, imminence, and impact of risk as well as indicators of areas which may require professional curiosity. SARs can help to spread awareness of risk factors which may be otherwise unknown, for example a perception, false or otherwise, that a person is a ‘paedophile’[15].  The Safeguarding Hubs need to be kept up to date with emerging risk indicators.

Team managers in Devon make their own decision on what form an Enquiry should take, based on the facts within the concern. If there is a need to use a multi-agency approach this could be indicated on allocation of the referral by the Safeguarding Hubs.  The team manager of CHSCT at the time was new into post and had limited experience of conducting safeguarding enquiries. DCC team managers have training on these matters and can contact the Safeguarding Hubs for advice.  However, it may be useful for new team managers to receive further information or support around any allocations they have limited experience of.  The Safeguarding Hubs are reported by DCC staff to be very approachable but there is still a reported inconsistency in documenting how a decision that the statutory criteria for s42(2) has been met, this can be a useful guide as to what next steps the allocated team should be considering.

Stephen enjoyed close working relationships with his support workers and is reported to have viewed at times as ‘family’. Lifeways have reasserted the policy of never giving personal phone numbers out to the people being supported and of only making alterations to rotas via the local office. Close working relationships over long periods of time will need boundaries and Lifeways will need to continue to be cautious of the possibility of these being breached.

[14]Appendix 1:
[15] AND

7.7 After Stephen's death

Support to practitioners and managers varied between organisations. Lifeways gave immediate support to staff and ensured access to counselling. They utilised an independent specialist to de-brief staff so that the demands of the organisation did not impact on the de-brief and staff information could be confidential. Group meetings for people who worked with or knew Stephen also occurred. Lifeways were not made aware of Stephens funeral by the funeral director. Two neighbours attended who were not well liked by Stephen and Lifeways do not know if his final wishes were all observed. They feel they let him down in this respect, they had known him for ten years and like many providers working consistently with isolated people, had become very close to him.

Devon County Council staff were not offered counselling or de-briefing. Stephen’s records were “locked down” and senior managers began to try to gather immediate learning. DCC staff report a sense of not being able to discuss what had happened “because it was a police investigation” although CHSCT did reach out to the Lifeways team manager. Team managers report looking after the needs of their staff, of their manager being supportive and of supporting each other informally. But they felt isolated, the organisation was ‘task focused’ on the learning, and not on the feelings and experiences of staff. DCC staff were not kept up to date with events, they followed the criminal trial via the media and were unsure if there would be a SAR.

Professionals involved with a person who has experienced a violent death will feel a range of emotions. They can experience feelings of shame, guilt, inadequacy, and loss of confidence[16].  They may not feel they should ask for support. De-briefing, emotional support and reflection can mitigate against these factors and minimise the risk of the professional experiencing a number of negative reactions, experiencing stress at work, learning the ‘wrong lessons’ or even leaving the service or profession

[16] Frost, E Magyar-Hass, V, Schoneville, H and Sicora, A (2020) Shame and Social Work: Theory, Reflexivity and Practice Policy Press.

8. What has changed since?

8.1 Stephen died almost three years ago, and much has changed, some as a result of the immediate learning organisations did after Stephen’s death.

8.2 CHSCT now uses risk assessment tools to quantify risk and share perceptions within a Multi-Disciplinary Team. This encourages a shared risk analysis. CHSCT note that “place based” reviews during the pandemic have led to a better connection with social care providers. There is more partnership work with providers, confined at the moment to the larger providers who have a lot of interaction with the team.  When teams have worked on a patch basis they have been able to get to know smaller providers and sometimes individual support workers.

8.3 DCC created an action plan based on the immediate learning from Stephen’s death. The plan includes an update to guidance on self-neglect to include the consideration of other risks, including Mate Crime, and to indicate the need for protection planning through a multi-agency Enquiry in such circumstances. Revised guidance does not appear to have been published yet but may exist internally.

8.4 DCC has embarked on a Rapid Improvement Programme to promote consistency of response and decision making in the three Safeguarding Hubs across Devon. This work is taking place over sixteen weeks and involves practitioners and managers in all aspects of Hub work, from utilising agreed risk assessment tools to improving partnership working.

8.5 Devon and Cornwall police initiated a Strategic Safeguarding Improvement Hub in early 2020 which is “a multi-disciplinary team working within a multi-agency environment to identify, develop and deliver improvements defined by the vulnerability strategy”. The Hub is responsible for improving police policy, practice, and performance in relation to relation to all thirteen “strands of vulnerability”, including adults with care and support needs.  The Hub will be able to take forward lessons from this SAR.

8.6 TDSAP published an escalation protocol in October 2021. Organisations vary in their awareness of the protocol but this is developing and will need to be continually encouraged.   TDSAP SAR Erik[17] (2023) recommends that the TDSAP “re-promotes its Safeguarding Adults Escalation Protocol to Partnership agencies” (Recommendation 10).

8.7 Lifeways now has a reporting system (Radar) which tracks actions relating to safeguarding concerns and can assist in identifying when matters need to be escalated.  As a direct learning from Stephen’s experience Lifeways have also reiterated and focused on the need to regularly review cancelled visits and identify the factors behind this.

8.8 Via training and other awareness raising activities DPT have reiterated the need for all safeguarding issues to be raised on the Trust risk system. IATT did not raise a safeguarding concern but did identify safeguarding issues in the SBARD. A new incident report would have alerted the Trust safeguarding team to the concerns and the open S42(2) enquiry being led by DCC, this would assist with communication and escalation. The GP surgery has also reflected on the need for escalation regarding a patient they have concerns about rather than reliance on one professional’s opinion about their wellbeing.


9. Findings and Learning Points

9.1 Were opportunities taken to identify that Stephen was at risk of abuse and/or being abused?

9.1.1 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.

9.1.2 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[18], 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.

9.1.3 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.

9.1.4 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.

9.1.5 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.

9.2 Were opportunities taken and processes robust enough to protect Stephen from abuse?

9.2.1 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.  Support worker 1 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.

9.2.2 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.

9.2.3 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

9.3 How was Stephen involved in the decisions and actions taken to protect him from abuse?

9.3.1 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.

9.3.2. 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 (see section 7.5.6) 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.

9.4 How did agencies work together to protect Stephen from abuse?

9.4.1 Without coordination agencies were unable to protect Stephen.  After the 13th October information about people going into his house was not shared. IATT withdrew their offer of arranging for Stephen having reasonable adjustments, the CoP team was uninvolved, there was no contact between DCC and Lifeways. Lifeways continued to try to work with Stephen’s GP. Although concerned the GP had allowed themselves to be reassured by their conversation with CHSCT on the 30th October. The investigating police officers made little contact with Stephen from mid-November onward. Support worker 1 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

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.

[18] Section 4 at

10. Conclusion

Stephen’s death was caused by the two people who murdered him. He was killed in the most brutal and cruel manner which has left those who worked closely with him immensely sad and sometimes angry. We cannot say that if we had protected Stephen more robustly these horrific events would not have occurred.  We also have no insight into any contact organisations had with the perpetrators of Stephen’s murder and whether there were other opportunities to prevent Stephen’s death.

The organisations who worked with Stephen have all contributed to reflections about what was done well with regard to protecting Stephen and about what we must improve upon.  This will perhaps be one part of his legacy. One of his support workers has said how amazed and happy Stephen would have been to realise how important he was to so many people, both when he was alive and now that we are trying to learn from the circumstances around his death.  If we work together within respectful partnerships so much can be achieved.

11. Recommendations to Torbay and Devon Safeguarding Adults Partnership

11.1 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

11.2 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

11.3 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

11.4 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 12.7 below

12. Recommendations to organisations

Recommendations 12.1-12.4 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 12.1 – 12.6 useful when considering Torbay procedures and practice in safeguarding adults.

12.1 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

12.2 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

12.3 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     

12.4 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     

12.5 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

 12.6 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

 12.7 All organisations are recommended to create contingency plans for employee support after a tragic or other high impact event.

Learning Point 8


Report author
Kate Spreadbury
Lead Reviewer