BREAKING NEWS: Publication of the Serious Case Review into the death of Rugby woman Gemma Hayter

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WARWICKSHIRE agencies have pledged their determination to work together on the lessons learned from the Serious Case Review into the death of Gemma Hayter.

Warwickshire Safeguarding Adults Partnership Board published the Serious Case Review today (Monday).

Gemma, 27, was found dead on a disused railway line in Hillmorton on August 9 last year.

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 which include:

A review and restructure of adult social care learning disability services

Strengthened adult social care case recording practice

New social care guidance for responding to vulnerable adults who may not have a formal diagnosis of a learning disability

The inclusion of district and borough housing services and GP representation on the Safeguarding Adults Partnership Board

The incorporation of autism workers on the adult social care learning disability team who support people with autism who do not have a learning disability diagnosis

The development of Extra Care Housing and Key Ring Schemes for learning disabled and vulnerable adults to live in the local community

In April 2010 Warwickshire County Council and the Coventry and Warwickshire Partnership NHS Trust entered into a legally binding partnership agreement that fully integrated mental health and social care teams. This means clinicians, social workers and community psychiatric nurses work alongside each other.

Coventry and Warwickshire Partnership NHS Trust implemented refocused guidance for the Care Programme Approach (CPA) used. The CPA promotes the consideration of family and carers in delivery of care. The CPA also includes a revised risk assessment toolkit.

The Trust’s Community Mental Health Team’s operational policy has been reviewed and re-formulated. A new supervision policy is also in place in the Trust.