Serious Case Reviews

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.

Completion of the Gemma Hayter Serious Case Review Action Plan:  ‘Work to safeguard vulnerable adults must continue’

Following the completion of the Gemma Hayter Serious Case Review action plan, agencies across Warwickshire have pledged to continue their work to protect vulnerable adults.

Wendy Fabbro, Chair of Warwickshire Safeguarding Adults Partnership Board and Strategic Director of People Group at Warwickshire County Council, said:

“Services across Warwickshire have learned significant lessons from the review into the tragic death of Gemma Hayter. By acting upon the recommendations and seeing them through we have been able to make a step change in the way we deliver services for vulnerable adults.

“While we know that improvements have been made and more people are being supported, we cannot be complacent and safeguarding services have to continue to develop.”

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 abhorrent, committed by people she believed to be her friends. The five people who caused her death were brought to justice, three of whom are serving sentences for murder and two for manslaughter.

Shortly after Gemma Hayter’s death, Warwickshire Safeguarding Adults Partnership Board commissioned a Serious Case Review with an independent chair. The purpose of this review was to enable the agencies which knew Gemma to review their involvement with her. The board decided to look both at the immediate circumstances associated with her murder, and also a much longer period of her life. Committed to learn from this tragic situation, the board wanted to improve the way agencies worked together as well as individual practice.

The Serious Case Review found that while Gemma’s murder could not have been prevented, lessons could be learned for the future.

Recommendations from the Serious Case Review were taken forward by the agencies involved and have brought about significant improvements and developments.

At the multi-agency Warwickshire Safeguarding Adults Partnership Board on 29 January 2014, the work undertaken by all agencies to address the recommendations was considered.

Wendy Fabbro, Chair of Warwickshire Safeguarding Adults Partnership Board and Strategic Director of People Services at Warwickshire County Council, said: “The board concluded that while the Serious Case Review action plan was now complete, there are ongoing steps that professionals will together continue to take, so we can protect and support vulnerable adults. Positive mate and hate crime initiatives, such as Safe Places, will also continue to grow and develop to help safeguard people in their local areas.”

She added: “In addition, we welcome the progress of the Care Bill through Parliament which will reinforce our Serious Case Review programme, putting the work of the safeguarding board on a stronger, statutory basis to protect vulnerable adults. Although we are already doing what is proposed in the new legislation, we will use this opportunity to strengthen our services further and work with communities to keep people as safe as possible.”

In response to the Gemma Hayter Serious Case Review, a range of work has been undertaken to respond to the recommendations, resulting in some significant service changes. To see the range of work please click on Summary of work in response to SCR recommendations.docx (DOC, 332.5 KB).

Serious Case Reviews was last updated on December 14, 2017.


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