Serious case review of woman’s death reveals support gaps

Major gaps in support for vulnerable adults with undiagnosed learning disabilities have been exposed by the exploitation and murder of a woman by people she considered her friends, a serious case review has found.

The murder of Gemma Hayter, who was beaten to death in August 2010 at the age of 27, could not have been predicted or prevented but agencies missed 23 opportunities to initiate safeguarding procedures or otherwise intervene to improve the quality of life.

In particular, the SCR, commissioned by Warwickshire Safeguarding Adults Partnership Board, identified inadequate support for adults at risk who lacked a diagnosis of learning disability and thus access to specialist support.

The SCR found clear evidence that Hayter had a lifelong condition that included significant difficulties relating to social functioning and communication and risks related to her behaviour, but never received a learning disability diagnosis.

“A system based on diagnosis was the key deciding factor that prevented Gemma from receiving effective and timely assessments and/or provision of support,” the review said.

“Fundamentally, the evidence shows that professionals recognised her life-long difficulties but felt restrained by the systems and protocols around diagnosis to offer her support – so there was confusion about who was ultimately responsible for offering that support.”

One result of agencies’ focus on diagnosis was that it was assumed that Hayter had the mental capacity to make certain decisions when this may not have been the case, according to the review.

In 2004, Hayter was allegedly raped and police asked a psychiatrist for judgement about her mental capacity. Police were advised that she did not have a learning disability and no mental capacity assessment or adult safeguarding investigation was completed.

Adult services also failed to conduct an investigation following evidence of Hayter’s exploitation by a pub landlord who asked her to look after drugs for him in 2005. His request led to Hayter’s arrest for possession.

The review also found that the local adult safeguarding threshold relied on a single trigger and thus failed to identify people at risk from a succession of lower-level incidents.

The review added that Hayter’s lack of formal plan for her transition from children’s to adults’ services, during which little information was passed on, potentially added to her difficulties later in life. Children’s services held “a wealth of information about her health needs and attempts to diagnose a condition that could explain her needs and vulnerability,” the review said.

Independent serious case review chair Kath McAteer said: “Though there was evidence that Gemma 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.

“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.”

Recommendations included for the safeguarding partnership board to develop procedures to ensure multiple low-level concerns about an individual are escalated and a strategy to tackle “mate crime”. It also called on Warwickshire Council’s adult social care department to ensure people with mild-to-moderate learning disabilities who do not meet eligibility criteria can access a needs and risk assessment on first contact.

Partnership board chair and council adult care director Wendy Fabbro said: “Gemma’s experience would be very different now because her transition into adult services was made before the full implementation of personalisation in 2007. Under personalisation, services would be assessing people on their vulnerability and not their medical assessment at all.”

Fabbro added that since Hayter’s murder, the council had been reviewing the cases of vulnerable adults in a similar position.

Earlier this year Chantelle Booth, Daniel Newstead and Joe Boyer were found guilty of murdering Hayter, while Jessica Lynas and Duncan Alexander were found guilty of manslaughter.

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