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Approximately 1.5 million people in the UK have a learning disability. 15 per cent of
these people have secured long-term tenancy or live in their own home. Until July 2006
39 year-old Steven Hoskin was one of this 15%. He lived in St Austell in Cornwall. On the 6th of
July his body was found at the base of the St Austell railway viaduct. Two people were found guilty
of his murder, Darren Stewart aged 29 and Sarah Bullock aged 16. Martin Pollard aged 21 was found
guilty of manslaughter. Darren Stewart the leader of this group was already known to police for his
criminal activities and for having complex unmet needs of his own. He had targeted Steen Hoskin
because of his learning disabilities. Steven desperately wanted friends and so accepted
Darren Stewart and the group into his life and home without recognising the true exploitative nature
of their friendship. Stephen's final hours of life were bleak in the extreme. He was tortured, forced
to wear a dog lead, coerced into swallowing an overdose of paracetamol and then made to leave
his home and walk to the railway viaduct near his house. Darren Stewart then made Stephen climb over
the safety rail and Stephen was forced to let go and fall to his death as Sarah Bullock kicked
his face and stood on his hands. Investigations uncovered the fact that Stephen had made several
calls and visits to a number of agencies, all of which should have alerted people to the
danger of his situation and his vulnerability. In 2000 the Department of Health and the Home
Office produced a document called No Secrets. It was a guidance document, guidance for social care and the
expectation was that agencies would work together to protect vulnerable adults. I guess in 2008 and
2009, following the series case review in Cornwall the gains have been really quite substantial and
Cornwall is doing all that the No Secrets document of 2000 aspired to do. It has taken a tragedy of
this magnitude to promote the partnership working that is sought in that guidance. No Secrets has now
been replaced by the Care Act. This reinforces the need for good communication, partnership working
and information sharing. The serious case review provided the opportunity to learn to look at what went
wrong, how improvements could be made and what's going right. It seemed to me that every agency
had a small piece of information or even quite a large piece of information but they looked at that
information as though it was disconnected from anything else and one of the principal findings
of the serious case review was that every agency had a piece of a jigsaw but at no stage did they
seek to discuss the piece that they held or the information or indeed the concerns that
they had about Steven's circumstances. I think each agency had such a strong sense of having
failed a very vulnerable man. That's not to say that these agencies are entirely without merit
or that they acted in a way that they were they knew of the danger that Steven was in they did
not see it coming so it had a very major impact on all services across sectors. It's a very tragic
murder and I think people's initial reaction to that was one of great shock and sorrow and I think
it's that the shock a sorrow still stays with us but actually what he provided was a real catalyst
for change and I think the process that we've gone through in Cornwall following that murder has
really been very positive in terms of basically taking safeguarding adults forward into a
much better place than it was before. I think every agency in Cornwall moved on very swiftly
from their painful self scrutiny and thought how can they make real safeguarding adults in the
county. So for example the police were required to read serious case review and to think hard
about neighborhood policing and very specifically about problem-solving policing. The
serious case review confirmed to the police had been called to Blowing House Close on
numerous occasions. Each time these were attended by different officers and seen as one-off events.
The review has forced this issue to be addressed. We have just introduced what we're calling the
neighbourhood harm register which looks at when we have repeat calls to the same people
with the same problems. A few years ago we didn't have that sort of structure so we were going
and dealing with the same incidents, not problem solving them and those incidents were going on
and leaving people more vulnerable. Can I just confirm that's a disorder at one of our vulnerable repeat
addresses? We have a mechanism where every week a station inspector will ask his team what problems
are they having at what addresses and what are we doing about problem solving it in partnership with
our other agencies here in Cornwall. The fact that it goes down to a neighborhood beat team level
gives personal ownership at a constable level to find the solutions. Similarly the ambulance
service which had not been able to deliver what's called a management review report to
the series case review undertook to do that even though the review had delivered its findings.
Undertook to do that in the 12 months after the review was published and to learn the lessons.
The serious case review prompted Southwestern Ambulance Services to question why they had not
picked up on the number of repeat call-outs to Blowing House Close. What we realised when we analysed
the case of the attendance of Steven Hoskin's address was that we've been on numerous occasions.
None of those individual incidents had raised enough concern to trigger an alert. We're much
better now looking at that in the context of a cluster of calls. As the series case review
pointed out, Steven's repeat use of NHS primary and secondary care services should have made him
more visible to them. Unfortunately this was not the case. Before the Steven Hoskin case we had no
way of knowing whether somebody had attended one, two, three, maybe four times into one of our minor
injuries and we also couldn't identify if they'd attended different minor injuries. Since
the Steven Hoskin case we've implemented the computerised system which also has set triggers.
The triggers are that if obviously if the nurse is concerned at the time they can trigger that
and can actually phone our unit and tell us. If somebody attends three times in one month,
three times in three months, or six times in six months, that automatically is notified to us by
the computerised system. We're also starting to share information with Southwest Ambulance Trust.
This was self-inflicted. Is it still in his arm at the moment? Okay, it's still there then do not
pull it out. Okay. If anything does get worse or change I need you to call us straight back on 999
but the ambulance is on its way. They're actually sending through to the safeguarding children
and adults team the addresses that they've been called out to more than three times in a month
and we're cross-referencing those within our own minor injuries alert to see if any of them are
the same. We're also cross-referencing them with people who are known to be vulnerable
adults with the information that's shared with us from department of adult social care so I'm
really very pleased with the amount of progress we've made with sharing information. We've still
got a way to go. We are still meeting with other agencies such as the police to see if
there's any way in which we can all share the information that we all are gathering around
vulnerable adults and addresses where vulnerable adults may live. Steven's accommodation of Blowing
House Close had been secured by adult social care. They set up a plan to include weekly visits
to his home. But in August 2005 Steven chose to discontinue his community care assistance
support. The serious case review questions why this choice was not investigated or explored.
After the Steven Hoskin case people felt very shocked and very very disappointed. It was also
on top of a previous inquiry that we'd had in Cornwall around learning disability services
so I think that the whole thing just impacted on a sense of failure in the department. Things have
improved vastly since the Steven Hoskin case. You know staff are trained now in a way that
they they weren't before, we've got processes in place, we've got leads I think. I'd like to
think that there's nobody that works for the department that isn't aware now of safeguarding
systems and alerts and what you do with alerts. I think there's a much greater likelihood that
somebody with Steven Hoskin's support needs would be identified now in Cornwall. Each of the agencies
has gone way beyond the minimal adjustment you could say an action plan is about they've hit
all the actions. That's good, they've gone beyond that. In the series case review Margaret Flynn
used the metaphor of pieces of a jigsaw and the fact those pieces of the jigsaw weren't being put
together and when we're doing work in relation to safeguarding adults then vulnerable adults'
lives are complex and they touch a wide range of agencies and if you want to know what's happening
with that person's life then you actually need to work with a wide range of agencies to put those
pieces together so that you can see the picture, so that you can take action before the tragedy
occurs, rather than picking up those pieces after it has occurred. And I think the a lot of the work
we've done in Cornwall since that review has been part of trying to ensure that agencies do
work much more closely together and do share that information so that actually we can start to see
that picture emerging in time to take action and if other areas can learn those lessons without
having to go through the same tragedy we went through here, then that's obviously very positive.
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