What does the murder of a man with a learning disability have to do with the NHS? Not as much as it should, according to Margaret Flynn, who conducted an official inquiry into the death of Steven Hoskin in Cornwall

Steven Hoskin's body was found on 6 July 2006 at the base of the St Austell railway viaduct. In addition to the catastrophic injuries associated with falling 30 metres, a post-mortem examination found that Steven's body bore evidence of torture: cigarette burns, neck bruises from the dog collar and leash he had been dragged around in, a lethal dose of paracetamol tables and alcohol, and footprints on his hands which finally caused him to fall to his death.

Steven was a vulnerable adult, whose needs were well known to the local NHS, council adult care services and housing services. But so too was Darren Stewart, the principal perpetrator of his murder. Last year, Darren was sentenced to 25 years in prison.

In late 2007, I chaired Cornwall county council's serious case review into the events leading up to Steven's murder. While there has been much deliberation on the culpability of social care services, I am struck that the implications for the NHS have been less explored.

Warning signs

So, what is the significance of the torture and murder of a man with a learning disability by a man who was an intensive user of emergency, primary care and mental health services? Who in the NHS takes responsibility for making adult protection referrals to the local authority and what is the real status of agreed multi-agency adult protection procedures to the NHS across all its services?

Many months before his murder, Steven was "targeted" by Darren Stewart.

As the police noted, "Darren Stewart had recognised the clear vulnerability of Steven Hoskin and 'moved in' on him... he recognised the opportunity for accommodation... [He] was fully aware of Steven's vulnerability and took full advantage of these facts to control both Steven and the premises."

Darren was well known to all NHS services, including mental health services. His own history was chaotic: from being a runaway child, he became a violent and self-harming young man, leading a nomadic existence and making frequent suicidal gestures. He had convictions for arson and assault. Within eight years, he had five children with three partners, all of whom were teenagers and two of whom were ex-care leavers, known to be vulnerable themselves. The relationships were volatile and emergency protection orders were sought for the children following the hospitalisation of one of his babies.

In the year and a half before Steven's murder, Darren Stewart made 24 calls to ambulance emergency call-out, at least eight of which were to Steven's bed-sit. By January 2006, the ambulance service knew Darren was dangerous and had a "warning marker" against him. Accordingly, they requested police attendance at all emergency visits. Although Steven was known to have a learning difficulty, the excessive use of emergency services by someone residing at his address did not result in an adult protection alert.

In the same timeframe, Darren made at least eight visits to accident and emergency services, seven visits to minor injury units, consulted his GP on 15 occasions and the out-of-hours GP service on 21 occasions. It does not appear that Darren's escalating use of NHS services, irrespective of his poor engagement with mental health services, evoked any concerted effort to bring it to a halt by finding out the reasons for such behaviour. Nor was his relationship with Steven explored.

Yet even the initial meeting of the serious case review panel confirmed that there was no lack of information about Steven and his circumstances. With better inter-agency working, he would have been spared the destructive impacts of unrestrained physical, financial and emotional abuse in his own home.

Missed connections

All agencies have legal responsibilities, not only to prevent harm being caused by their own agents, but to safeguard vulnerable people against the harmful actions of third parties. What is striking about the responses of services to Steven's circumstances is that each agency, including the NHS, focused on single issues within their own sectional remits and did not make the connections deemed necessary for the protection of vulnerable adults and proposed by No Secrets, the multi-agency adult protection guidance published by the Home Office and Department of Health in 2000.

No Secrets urged the establishment of local multi-agency adult protection committees charged with ensuring joint working and information sharing to keep vulnerable adults safe. For the NHS, this should have meant integrating adult protection procedures into clinical governance, systems for complaints, adverse incidents and professional standards. But in practice, No Secrets - which is still only guidance rather than obligatory - has left a host of unanswered questions for the NHS:

  • As there is no requirement on the NHS to employ a lead officer to deal with adult protection, how do acute, mental health and primary care trusts determine who should contribute to the work of adult protection committees and do their nominees have the authority to make strategic and resource decisions?

  • What level of resources is devoted by trusts to ensure all staff are properly trained in adult protection procedures and practices?

  • While the adult protection efforts of local authorities are scrutinised by the Commission for Social Care Inspection, how are adult protection and safeguarding processes in trusts monitored and what reporting is required by trust boards or strategic health authorities?

  • What incentives are there for the NHS to discard or replace ineffective safeguarding practices?

  • Are there natural NHS adult protection "champions", as radiologists once were in respect of child protection?

  • Are PCTs ensuring that safeguarding and its monitoring are integral to all contracting arrangements with providers of their services, including GPs?

  • Do GPs charge for submitting evidence and attending strategy meetings for example and if so, who should pay?

Despite these unanswered questions, the serious case review of events leading to Steven's murder established that there should be clear "thresholds" for adult protection referrals (as there are for children) which, if breached, should always result in contact with the council adult social care services. These include:

  • any more than three presentations to accident and emergency or a minor injury unit by a vulnerable adult within a period of three months;

  • any vulnerable adult who presents to accident and emergency or a minor injury unit having been assaulted or having taken an excess of drugs and/or alcohol.

But in Steven's case, NHS personnel did not appear to regard themselves as potential "alerters" or even the recipients of direct and indirect requests for assistance. When Steven discontinued his contact with adult social care, his visits to primary care increased. A physical assault is a traumatic event and even though Steven told staff that he had been assaulted, he went home from secondary care alone and there was no adult protection alert.

Further, primary and secondary care personnel knew Steven was drinking to excess and they gave him the contact details of the drugs and alcohol service. But Steven could not read and his alcohol abuse did not evoke the necessary "alert" from any healthcare personnel. This is despite clear guidance from the British Medical Association that in the case of a vulnerable adult or child, protection must take precedence over confidentiality. If primary and secondary healthcare personnel had been attuned to Steven's learning disability and his vulnerability, arguably his visits could have been regarded as alerts.

Case for change

What happened to Steven raises fundamental questions about the adult protection and safeguarding role of the NHS. This year, the Department of Health is reviewing the No Secrets guidance. Arguably, Steven's murder presses the case for:

  • a statutory requirement to establish adult protection committees;

  • consistent and board-level NHS representation on adult protection committees and safeguarding adult boards;

  • a statutory duty to co-operate with serious case reviews;

  • the need for clear risk criteria and "thresholds" for making adult protection alerts;

  • a review of all information sharing protocols within the NHS in each strategic health authority - most particularly where concerns regarding confidentiality have eclipsed adult protection;

  • internal monitoring of adult protection processes in acute, primary and mental health trusts;

  • an explicit role for strategic health authorities in monitoring adult protection performance;

  • national performance indicators;

  • the need to share information within and across all NHS services, including the out-of-hours service;

  • the identification of an adult protection "lead" GP in each PCT;

  • specified NHS monies invested in multi-agency training.

At Steven's murder trial, Mr Justice Owens expressed his grave disquiet about the role of the adult social care service. It is worrying that this focus on social care has persisted since the serious case review. The review identified major failings in all services, including the police, children's social care, the NHS trust, the PCT, the ambulance service and housing.

If the Department of Health's review is to promote ever greater investment in partnership working in safeguarding adults, then all "partners" should be perceived as responsible. If the review of No Secrets is to achieve more effective practice in safeguarding adults, the NHS must play its full and proper role in achieving that improvement. This will include better-trained staff, clear systems of performance monitoring and review, information sharing across the NHS and between the NHS and other statutory partners, and investment. The NHS failed Steven Hoskin. The best testament to his memory is that the NHS nationally, as well as in Cornwall, learns the lessons.

Find out more

BMA guidance on domestic abuse and confidentiality

Serious case review: the murder of Steven Hoskin

No Secrets guidance