Safeguarding Adults: Lessons from the murder of Steven Hoskin

September 23, 2019 posted by

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.

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