NIASP/NIASW Shared Learning Event

1. NIASP/NIASW Shared Learning Event Learning The Lessons From Complex Cases In Adult Protection

2. Learning lessons from Adult Serious Case reviews Margaret Flynn November 2013

3. What are we talking about? • Taking decisive action • Exceptional and messy incidents • High stakes territory • Untested processes • “Something good needs to come from this tragedy” • “They all say the same thing” • Disconnected from the parallel processes within the NHS • Contested rationales • The circumstances of abuse – ranging from minutely subtle interactions to gross violations of human rights

4. Steven Hoskin 1967-2006

5. A victim of bullying • Takes place in the general interactions of children and young people • Generally hidden from the adult supervising world • Being different in some way is a risk factor for being bullied • Factors predisposing to bullying behaviour include: violence in a family; lack of warmth between parents or family; no clear guidelines for behaviour or monitoring activities

6. A victim of cruelty • Most cruelty is about callousness. It may involve failing to realise, ignoring, or deliberately downplaying the harmful effects of cruel behaviour on victims, or it may involve the belief that harm is justified: fair punishment rather than unfair vindictiveness… • (K Taylor, 2009)

7. Failures haunt all atrocities • Steven was “victimised” when he was in an Assessment and Treatment Unit • His home life became characterised by conflict after the death of his grandfather who shared the family home • He began to drink – ultimately excessively • A housing application noted “he is very vulnerable and can be taken advantage of due to the way he looks i.e. his learning disability” • Steven acquired a lodger – in his one room bed-sit • Young boys were hanging around, frequenting his bed-sit and misusing substances

8. “He tried to do as others do” • Failing to challenge beliefs e.g. “He’ll be in touch when he needs help” • Failing to check beliefs against reality… • Failing to intervene and challenge – or comment on behaviour

9. The reality “Steven did not see that the friendship he so prized was starkly exploitative, devoid of reciprocity and instrumental in obstructing his relationships with those who would have safeguarded him.” • Cease to deify a person’s “choice” and ask “I wonder if someone is exerting pressure?” • Task-driven health and social care may result in case closure without any consideration of the risks • Recognise the risks to which some Direct Payments Recipients are exposed “I’m not your Personal Assistant, I’m your girlfriend…We’re not like employer-employee – we’re more like friends – great mates”

10. Michael Gilbert 1982-2009

11. Michael’s life… • All but his youngest sibling were in care at different stages • Household characterised by trauma, turmoil and strained finances – intermittently a single parent household • An inconclusive investigation of alleged sexual abuse influenced subsequent events – initially, he lost his previously exalted and protected position as “favourite” • He was bullied at school and in homes • He had a mastectomy at 13 years • He participated in street crime • Between ages 15-17 years he had 12 moves between children’s homes, foster carers, a hostel and a night shelter for young people

12. As an adult… • He developed bonds with persistent offenders “who would not benefit him long term” • It’s unlikely that he had the skills to stay safe • He rejected assistance for injuries • His enthusiasm for courses and being accommodated was short lived • He was subject to sexual name calling and bullying • His allegations about being kidnapped / falsely imprisoned by a family were not believed • From being nomadic he became enslaved and was tortured • Ultimately Michael regarded himself as a member of the kidnapping family and felt “supported” by them

13. The resources of agencies… • Hinged on steering Michael to other placements • Were diluted by weaknesses in the support of care leavers • Did not place Michael’s safety in the foreground of their responses • Were not directed at negotiating a child protection path • Did not result in clarity about how to intervene “It is possible that Michael developed undiagnosed mental health problems but neither his history nor serial homelessness (including refusals of help) resulted in heightened professional concern or credible intervention….Too much was expected of Michael…when he had neither the maturity nor judgement to identify the safe companionship of trusted others.”

14. Ann and A N Other

15. Markers that things aren’t right • Discourtesies • Threats of legal action • Refusing access to their properties or access only achieved after protracted “prior negotiation” • Concerns about rodents/ rubbish in an untidy garden • Potential S.47 National Assistance Act 1948 considered • In breach of implied terms of tenancy – did not take proper care of properties, rent arrears • Central heating declined • Long term non-co-operation

16. Opportunities to intervene • Stock condition surveys • Care and repair • Smoke alarm installation and maintenance • Access to gas meter • Rent arrears Person to person contact is essential with tenants who are at risk of abuse and neglect

17. Institutional abuse • Who is at risk? • The role of the media and public awareness • Training and education • Custom and practice • Community links • Inter-agency collaboration

18. Crucially… • It is devastating to be abused – the scale is unknown • Abuse comes in many guises and is well served by disbelief, eligibility criteria and poor service responses • It is easy to trick, befriend and steal from silent victims • Disadvantage does not self correct and legislation will not eliminate abuse • Unwise decisions do not remove risks • Abuse steals lives and collapses everything that is familiar • Mutually loving relationships have a protective role • All kinds of organisations can generate a culture of perverted loyalty – rendering abuse under-recognised and reported • Our histories can get in the way of reporting

19. Finally… “When fellow human beings are deprived of consciousness and language, for either short or enduring periods of time, we with consciousness, language and conscience must listen and act on their behalf.” Ruthann Knechel Johansen (2002)