At the heart of the Serious Case Review were two uncomfortable and haunting realities

At the heart of the Serious Case Review were two uncomfortable and haunting realities. Firstly, Mr Hoskin was regarded by several agencies not as a vulnerable adult to be protected from abuse and neglect but as a perpetrator of antisocial behaviour and worse. Mr Hoskin had been charged and convicted of assault. He was known to be verbally abusive when drinking. There were complaints from neighbours about noise and worse emanating from his bedsit in St Austell. The fact that many agencies knew that Steven was a vulnerable adult with learning disabilities (including: Ocean Housing, the police, adult social care, the NHS and the Youth Service) was subjugated to their day to day experiences of responding to him. He was experienced as being at the heart of many and repeated social and health problems where he lived. There were the repeated complaints from neighbours and emergency calls to the police resulting in many visits to Steven’s bedsit. There were the complaints to Steven’s landlord, Ocean Housing, including a petition from his neighbours about noise and nuisance problems in the days before his murder. There were several emergency calls to the ambulance service to come to the bedsit to care for Steven, and those later found guilty of his murder – with alcohol and violence often at the heart of the problems encountered when the ambulance crew arrived. Adult social care had “tagged” Steven’s file because of the assault he had perpetrated against his mother and thus they also understood Steven not only in terms of his vulnerability – but also in terms of the risk he posed to others.
This information was taken from the following article : www.communitycare.co.uk
The body of Steven Hoskin was found at the bottom of a railway viaduct in St Austell, Cornwall, on 6 July 2006. Hoskin, who had learning disabilities, had suffered hours of abuse at the hands of a gang, two of whom – Darren Stewart, 29, and Sarah Bullock, 16 – were convicted of his murder, and one – Martin Pollard, 21 – of his manslaughter. In his final hours, the 38-year-old service user was forced to swallow a lethal dose of paracetamol, was hauled around his bedsit by a dog lead and burned with cigarettes. Then he was frogmarched to the viaduct from where he fell more than 30 metres to his death after Bullock kicked him in the face and stood on his hands.
A serious case review (SCR), published in December 2007, found that health, social care, housing and police had missed warning signals that ought to have invoked adult protection procedures. Since then statutory agencies in Cornwall have worked hard to meet the SCR’s recommendations.
Five years on, SCR chair Margaret Flynn says Cornwall “certainly has an edge in terms of engagement with emergency services”, compared with elsewhere.
She says that improving safeguarding requires explicit investment, and that some – though not all – authorities have considered the implications of the Hoskin case in detail.
What went wrong? In April 2005, Hoskin was allocated two hours of support each week by Cornwall Council adults’ services. But in the August he chose to cancel the service and by September his case was shut.
According to the SCR, Hoskin then “lost all control of his own life” when Stewart and his girlfriend, Bullock, moved into his bedsit and began to abuse him. The SCR added: “Steven’s ‘choice’ to terminate contact with adult social care was not investigated or explored with him, or other key agencies involved in his care, even though such choices may compound a person’s vulnerability; may be made on the basis of inadequate or inappropriate information; or result from the exercise of inappropriate coercion from third parties.”
What the SCR recommended: Any life-transforming decisions by a known vulnerable adult – such as discontinuing a support service – should result in assessments of a person’s decision-making capacity.
What has happened in Cornwall? Adult care staff must complete a risk assessment review before closing a case, overseen by a care manager. Cornwall Council has also introduced a quality assurance framework whereby a mixture of open and closed cases are selected monthly by line managers who examine them against four key measurements: whether safeguarding procedures were followed and recorded accurately; whether safeguarding actions were implemented; whether there is strong evidence of the service user’s voice in the process; and the outcomes for the individual and others.
“If someone says they don’t want a service, you need to look behind that,” says Jon Dunicliff, safeguarding adults co-ordinator for Cornwall’s independent safeguarding adults unit, which is accountable to the multi-agency safeguarding adults board.
“Choice is not a take-it-or-leave-it option. Even if they don’t want contact with social care, they will have contact with their GP, district nurse or their beat officer. That individual can be the best person to watch what’s happening, so it’s about using that range of multi-agency partners to stay aware of what’s going on in their life.”
What has happened nationally? David Congdon, head of campaigns and policy at Mencap, says: “There is a danger that a philosophy of choice – which is absolutely right – can be used as an excuse for inaction. With hard-pressed social services, if someone says they don’t want support it becomes convenient not to provide it. The starting point, but not the end result, is for the government to put safeguarding on a firm statutory basis.”
The body of Steven Hoskin was found at the bottom of a railway viaduct in St Austell, Cornwall, on 6 July 2006. Hoskin, who had learning disabilities, had suffered months of abuse from a gang, two of whom – Darren Stewart, 29, and Sarah Bullock, 16 – were convicted of his murder, and one – Martin Pollard, 21 – of his manslaughter. In his final hours, the 38-year-old was forced to swallow a lethal dose of paracetamol, was hauled around his bedsit by a dog lead and burned with cigarettes. Then he was frogmarched to the viaduct from where he fell more than 30 metres to his death after Bullock kicked him in the face and stood on his hands.
A serious case review (SCR), published in December 2007, found that health, social care, housing and police had missed warning signals that ought to have invoked adult protection procedures. Since then statutory agencies in Cornwall have worked hard to meet the SCR’s recommendations.
Five years on, SCR chair Margaret Flynn says Cornwall “certainly has an edge in terms of engagement with emergency services”, compared with elsewhere.
She says that improving safeguarding requires explicit investment, and that some – though not all – authorities have considered the implications of the Hoskin case in detail.
On whether there could be another death like Hoskin’s, Flynn admits “it is possible” but adds: “Some authorities have given a lot of thought to what it would have been like if he was resident in their authority and that’s more enlightened than thinking ‘thank god it didn’t happen here’.”
INFORMATION SHARING
What went wrong? Each agency focused on single issues within their own remits and did not connect them. The SCR said: “Each held a piece or pieces of a jigsaw puzzle without any sense of the picture they were creating, or indeed the timeframe within which the puzzle had to be completed.”
What the SCR recommended: A profes­sional who comes into contact with a vul­nerable adult should be able to determine immediately whether other agencies are involved and has a duty to share concerns.
What has happened in Cornwall? In March 2009 a trigger protocol was introduced. This amalgamates information from the flagging systems from the minor injury units (MIUs) and A&E and frequent calls from the same address to the ambulance service and the police on one database held by the primary care trust.
A monthly meeting discusses the 15 addresses that cause the most concern. Representatives from adult care, children’s services, the PCT, the safeguarding adults unit, the ambulance trust, police, the mental health trust and the fire brigade attend.
The PCT’s designated nurse for safeguarding adults, Chris Parish, who chairs the meeting, says: “Frequent-caller information is logged by address and we share that first rather than a person’s name. Darren Stewart was a frequent user of services and no one picked up that he and Hoskin were living at the same address.”
What has happened nationally? “There are some things that practitioners can’t share without checking them and, in the white noise of daily practice, it can be difficult to know who to check them with,” says Flynn. “But people are trying hard to share information.”
NHS FAILINGS
What went wrong? Hoskin often used health services after he stopped his support service. The SCR said: “If primary and secondary healthcare personnel had been attuned to Steven’s learning disability, arguably his visits could have been regarded as ‘alerts’.”
What the SCR recommended:
Thresholds should be introduced to trigger safeguarding alerts based on vulnerable adults’ attendance of A;E or MIUs.
What has happened in Cornwall? NHS Cornwall and Isles of Scilly introduced an electronic system linking the county’s 11 MIUs to identify multiple attendances. Emails are sent automatically to a dedicated email address at the safeguarding children and adults team when the MIU nurse has concerns at the time of the ­consultation or someone comes in three or more times in one month, three or more times in three months, or six or more times in six months. Emails are checked daily.
“We ask the MIUs to send us a copy of the patient’s treatment card so we can scrutinise them and check whether everything is being done that should be,” says Chris Parish, the PCT’s designated nurse for safeguarding adults.
The team identifies patterns of attendance and areas of risk, and is responsible for ensuring action is taken.
The A&E department at Royal Cornwall Hospital in Truro introduced a similar flagging system, although it is not on the same computer system as the MIUs’.
“Their system checks whether someone has come in more than three times in any time period. When that happens, the clinician who sees them on their fourth visit is alerted,” says Parish.
What has happened nationally? Pete Morgan, chair of the Practitioners’ Alliance for Safeguarding Adults UK, says agencies are “getting better at having systems in place to pick concerns up”, and this goes beyond health.
“By involving agencies like housing they can pick up on low-level concerns which as individual incidents may not ring alarm bells but put them together and they should do,” he adds.
Despite significant additional resources being devoted to adult protection arrangements in Cornwall, there were a number of “missed opportunities” which, if followed up, may have prevented Steven’s murder. These missed opportunities include a failure to make adult protection alerts for Steven when there was a clear indication that it was appropriate to do.