QS Safeguarding Case Review Report
1.
Introduction
1.1
Essex Safeguarding Adults Board have completed a table top review into the
death of QS. The aim of the review has been to ascertain the facts, analyse
them and identify any lessons that need to be learned. It is important to
emphasize that the aim of the review is not to investigate the incident or to
apportion blame but:
 To establish whether there are lessons to be learnt from the
circumstances of this case about the way in which local professionals and
agencies work together to safeguard vulnerable adults
 To review the effectiveness of procedures (both multi agency and those of
individual organisations
 To inform and improve local inter agency practice
 To improve practice by acting on learning and developing best practice
1.2
Terms of reference for the review were:
i. To investigate the involvement of local agencies who were involved with
QS from January 2001 to the incident on 9 July 2012 with particular
emphasis on the period from January 2010 to 9th July 2012
ii. To establish whether there are lessons to be learned from the partnership
working in this case
iii. To explore if relevant guidelines and procedures, particularly in relation to
the Mental Health Act and Mental Capacity Act were utilised in relation to
the case.
iv. Identify and consider their involvement with relevant family, friends and
neighbours during the18 months prior to the incident
2.
Process
2.1
The process followed for this review was based on the ESAB’s Multi-Agency
Serious Incident Review guidelines in that reports were requested from all
agencies who had involvement with QS
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Police
Social Services
Ambulance Service
Acute Hospitals
Mental Health Partnership Trust
General Practitioner
Fire and Rescue Service
2.2
Rather than completing an overview report a meeting was convened with
representatives from key agencies facilitated by an Independent chair to
review the content of the submitted reports and develop recommendations
and actions based on the information provided. Additional information and
further expert advice was also requested to confirm recommendations in one
particular area.
3.
Case Summary
3.1
QS was a 64 years year old male who had lived in his local area since 2001.
He had a history of being in dispute with different neighbours since 2003
culminating in the incident in July 2013 that resulted in the death of a police
constable and his subsequent suicide.
3.2
Since 2001 QS has had limited contact with statutory agencies. This has
primarily been:

health organisations - QS had a history of mental health problems
dating back to 2001 including suicide attempts and detention under
S136 of the Mental Health Act. These were managed by medication
through his GP from 2004.
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Police – Reports related to disputes with neighbours and low level
concerns about crime in the local area. It is however important to state
that during the period of the review there is no pattern to the reports
and they are not at a frequency that would cause a major concern or
necessitate further action
4.
Good Practice
4.1
QS’s GP during 2001 should be commended for the thoroughness of his
enquiries when QS apparently disclosed to him that his move into the area
from a different part of the county was as a result of being “on the run” from
drug dealers. The GP made contact with the police to discover whether this
information was correct or possibly delusional as a result of his mental health
issues.
4.2
The review also considered that the Police Community Support Officer’s
(PCSO) recording represented good practice when QS reported to a police
station some distance from his home address concerns about his neighbours
alleged illegal business activities. Although there was no further police
actions, and therefore no requirement to make a record the PCSO did put
down details on the police system providing useful information should QS
report similar concerns in the future.
4.3
The development by Essex Police of a staged risk based approach to the
recording and management of anti-social behaviour. Recognising that some
victims are more vulnerable to the harm that anti-social behaviour can cause
it is essential that an attending officer correctly identifies the risk associated
with a particular victim so that the correct level of intervention and support can
be delivered.
4.4
If the officer is content that the matter is an isolated case, there are no issues
of repeat victimisation, vulnerability or other aggravating factors they will
resolve the matter there and then and record the action taken. If however the
officer does identify any issues of concern, repeat victimisation or vulnerability
they will complete a threat, harm and risk (THR) assessment and record the
risk within the incident.
4.5
This is a staged approach whereby those considered to be at the greatest risk
are given the maximum potential level of support. Specific question
sets/prompts have been built into the incident file, providing a structured
framework of interventions and considerations. These questions sets are
cumulative in nature i.e. when a gold response is identified, regardless of the
number of previous calls, all prompts and considerations contained with
bronze and silver question sets should be recorded.
5.
Recommendations
5.1
All agencies should remind their staff of their responsibilities as set out in the
Southend, Essex and Thurrock Safeguarding Adult Guidelines, in particular:
i.
ii.
To ensure that all staff members are aware of their responsibility to report
safeguarding concerns
In circumstances where more than one agency is aware of an incident to
ensure that at least one agency formally reports the concern, even if this
may potentially result in multiple reporting of the same incident.