This is Steven Hoskin.
On the 6th of July 2006, Steven was murdered. 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 recognising 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
as Sarah Bullock kicked his face and stood on his hands. Steven fell to his death.
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.
Following the death of Steven Hoskin a serious case review
headed by Margaret Flynn, found a series of failings in joint working and information sharing.
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 knew
the danger that Steven was in, they did not see it coming. So it had a very major impact
on all services across sectors. Each individual agency, the ambulance service, the police service,
social services, knew some of the issues that Steven was facing but didn't talk to each other
but also even within their own organisations, there wasn't good enough information sharing so
each individual call that Steven would make, each individual incident was was viewed as a
one-off and it was a failure to spot patterns that contributed in the end to his death.
Safeguarding adults now comes under the Care Act 2014.
This reinforces the need for good communication, partnership working and information sharing.
Under section 42.1 of the Care Act, safeguarding duties apply to an adult
who: has needs for care and support whether or not the local authority is meeting any of those needs;
and is experiencing or at risk of abuse or neglect; and as a result of those care and support needs is
unable to protect themselves from either the risk of or the experience of abuse or neglect.
Unfortunately, research into the findings of safeguarding adult reviews since the Care Act,
shows that the same problems persist. There have been a number of safeguarding reviews
both before and after the implementation of the Care Act the highlight that the
case of Steven Hoskin is not unique. Sadly, hate crime, disability hate crime, the murder
and oppression of people with learning disabilities and other kinds of disability continues.
Research carried out by Professor Michael Preston-Shoot and Professor Suzy Braye
into safeguarding adults reviews has identified a number of themes that remain problematic
including information sharing and joint working.
So communication and collaboration emerges as as a key issue. Part and parcel of that
is information sharing. There are again good examples of information sharing that emerge from
safeguarding adult reviews but a consistent theme is a misunderstanding of the Data Protection Act
2018. A misunderstanding of the legal rules and specifically a failure to appreciate
that Article 8 of the European Convention, the right to private and family life, is a qualified
right. And that both the Human Rights Act 1998 and the Data Protection Act 2018 permit the sharing of
information without consent when that is necessary. I think in the years since, partly as a
result of Steven's death, partly just gradual awareness of good practice
arising sometimes from similar stories elsewhere, there has been progress you do see an increasing
number of multi-agency safeguarding hubs or mashes where police social services ambulance
services are all in the same room together, and are sharing that information more broadly.
Still, however, I think and Michael Preston-Shoot's review of safeguarding
adult reviews where things have gone wrong, it illustrates that there is still a tendency
to work, I mean he talks about parallel lines. You know that each agency is
working very well with someone but they are working in parallel rather than joining up.
I think joined up models of service delivery make this sort of information
proper information sharing easier. They're they're not the whole solution but
a multi-agency safeguarding hub where people do feel confident about their right to see
other agencies' files where leaders of organisations
role model that joint working. I think that has to be part of it, we do still need to
get better at integrated joined-up working and information sharing around safeguarding cases.
I think other recommendations would inevitably involve people genuinely understanding
the law around this so a greater degree of legal literacy amongst social workers, police, ambulance
drivers and so on so that's legal literacy around the Care Act and what that says about safeguarding,
legal literacy around the Mental Capacity Act, but also about some of the more tricky
interventions that can be used, sort of using the inherent jurisdiction of the High Court,
things like that that i think not enough people in the sort of safeguarding arena
fully understand so I think you know more training and awareness has got to be part of it.
But just throwing one day's training or an e-learning course at people
isn't going to do it. As I said there needs to be that kind of senior leadership and the
embedding of a culture whereby people will work jointly and will share information appropriately,
to make sure that people are kept safe as much as possible. And if there is one message that
I would invite listeners to take away, it is convene the system, bring people
together. So convene the system, make sure that everybody who has a contribution to make is there.
Make sure that the decisions are fully recorded, that somebody is responsible for overseeing
the plan and that there is a backup plan. If Plan A as it were doesn't work out.
Margaret Flynn compared the information in Steven Hoskin's case to pieces of a jigsaw. If we are to
put the pieces together when working with people whose lives are complex and risk is identified,
then all levels within all partner agencies need to play their part.
Key learning points to improve practice:
At a case level: Ensure a key worker and lead officer are appointed.
Agree a plan and a contingency. And put the person at the centre of everything you do.
At a front line level: Raise awareness about safeguarding among frontline workers,
people using services, carers and the public. Encourage vigilance, ensure everyone knows
how to spot abuse and neglect. And publicise the contact details and ways of reporting concerns.
At an operational level: Encourage an open culture in organisations. Promote positive
working relationships and joint working across key sectors. And ensure managers understand information
sharing law to enable them to share information with the right people at the right time.
At a strategic level: Develop local joint working strategies to enable effective
information sharing and coordinated responses. Ensure accountability is clear and a named lead
officer is appointed in each key organisation. And support from the safeguarding adults board
for lead officers to ensure compliance with partnership duties across sectors.
Getting it right at strategic level is absolutely key to ensuring every other
level in each partner agency is able to contribute to good multi-agency working.
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