Warwickshire County Council
Serious Case Review
The purpose of a Serious Case Review is not to reinvestigate or apportion blame but to establish whether lessons can be learnt from the circumstances of a case that may improve practice or the way in which agencies and professionals work together to safeguard vulnerable adults. The focus of serious case reviews, in line with both multi-agency policy and national guidance, is to:
- Learn from past experience and the specific event examined;
- Improve future practice and outcomes by acting on learning identified by the review;
- Improve multi-agency working and compliance with any other multiagency or single agency procedures; including, regulated care services.
Serious Case Review: the tragic death of Gemma Hayter
Key agencies in Warwickshire have pledged their determination to work together on the lessons learned from the Serious Case Review into the tragic death of Gemma Hayter.
Warwickshire Safeguarding Adults Partnership Board published the Serious Case Review today (14 November).
Twenty-seven year old Gemma Hayter’s body was found on 9 August 2010 on a disused railway line in Rugby. Her murder and the abuse that she suffered beforehand were truly abhorrent, committed by people she believed to be her friends. The five people who caused her death have been rightly brought to justice, three of whom are serving sentences for murder and two for manslaughter.
Gemma was a vulnerable adult who was known to a number of agencies throughout her life. Warwickshire Safeguarding Adults Partnership Board (WSAPB) commissioned a Serious Case Review last Autumn to examine in detail the way that services worked with Gemma and to make recommendations to better safeguard individuals in the future.
The Serious Case Review was independently chaired and authored by Kathy McAteer, a senior social care consultant and former director of adult services. Extensive information was gathered, which dated back over 10 years and included 11 of the key agencies involved in Gemma’s life.
Wendy Fabbro, Chair of Warwickshire Safeguarding Adults Partnership Board and Strategic Director of People Services at Warwickshire County Council, said:
“The Adult Safeguarding Board welcomes this rigorous report which highlights implications for all agencies who support vulnerable adults in our communities. There is a shared determination amongst all agencies to learn the lessons from this review and act upon the recommendations so we can take robust, positive action to minimise risks to vulnerable adults in the future.”
In summarising the findings of the Serious Case Review, Independent Chair Kathy McAteer said:
“While there was no evidence that Gemma’s murder could have been prevented or predicted, if she had received and accepted better support, she may have lived a better life and been less likely to fall into the company of people who presented serious risks.” “Gemma was a vulnerable young woman with lifelong difficulties who highly valued her independence. Though there was evidence that she was regularly exploited by people who knew her and she was known to many agencies, no single agency had a full picture of her life and the level of risk she was exposed to. Like all of us, Gemma wanted friends and a social life and this case raises wider issues nationally about community safety for single adults who may be vulnerable to disability based harassment, hate or mate crime and exploitation.”
The report makes recommendations for action from Warwickshire Safeguarding Adults Board, Warwickshire County Council Adult, Health and Community Services, Coventry & Warwickshire NHS Partnership Trust, The Local Medical Council and GP Consortia (Clinical Commissioning Groups), Rugby Borough Council, Warwickshire Police and Warwickshire Probation Trust.
The Warwickshire Safeguarding Adults Partnership Board has produced an action plan to address the recommendations, and a number of key improvements have already been implemented.
Here you can read a copy of the full public summary (pdf, 220kb)
