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 Steven Hoskin because of his learning disabilities.
Steven desperately wanted friends
and so accepted Darren Stewart and the group into
his life and home without recognizing the true exploitative nature of their friendship.
Steven'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 Steven climb
over the safety rail and Steven 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 Steven 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.
Um...I guess in 2008 and 2009, following the Serious 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.
Uh...It has taken a tragedy of this magnitude
to promote the partnership working that is sought in that guidance.
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 Stephen'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 knew of the danger that Steven was in.
They did not see it coming...um... 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 that the shock and sorrow still stays with us
but actually what it 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 for adults in the county.
So for example the police were required to read the Serious Case Review
and to think hard about neighborhood...neighborhood policing
and very specifically about problem solving policing.
The Serious Case Review confirmed that police had been called to
Blowinghouse 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 neighbourhood-beat team level gives personal ownership
at a constable level to find the solutions.
[siren]
Similarly the ambulance service, which had not been able to deliver what's
called a management review report to the Serious Case Review undertook to do that,
even though the review had delivered its findings, undertook to do that in the
twelve 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 Blowinghouse Close.
What we realized, when we analyzed the 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.
[...the emergency? Thank you, what's the problem? Tell me exactly what's happened.]
[Is that from another fall or..]
We're much better, now, at looking at that in the context
of a cluster of calls.
As the Serious 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 Hoskins 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 had attended different minor injuries.
[..sit on the trolley there for me.]
Since the Steven Hoskins case we've implemented the
computerized 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
computerized system.
[Ambulance service phone call]
We're also starting to share information with the Southwest ambulance trust.
[...and the knife slipped through his arm? 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 alerts to see if
any of them are the same. [Ambulance phone call]
[Have you got the name flagged?]
[What's your log number for that one?]
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 Blowinghouse 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 Hoskins case um, people felt very shocked
and ver... very disappointed.
Um...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 Hoskins 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... um...that
somebody with Steven Hoskins' support needs would be identified now, in Cornwall.
Um...the... each of the agencies has gone way beyond the minimal adjustment
that you could say an action plan is about.
They've hit all the actions. That's good.
They've gone beyond that.
In the Serious 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 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... um... 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.