Serious Case Review: Steven Hoskin (2007)
Local authority: Cornwall County Council
What happened?
Steven Hoskin lived alone in St Austell, he had a learning disability placing him at risk of abuse. He was befriended by people who subjected him to abuse. He was tortured and drugged before being dragged to a viaduct where he was forced to hang from railings before falling to his death. His post-mortem revealed Steven had signs of prolonged abuse.
Prior to his death, Steven had contacted different agencies over 40 times, including the police and health and social care agencies to indicate he felt he was in danger.
What went wrong?
Following the Serious Case Review (SCR), the following areas were found to have contributed to Steven’s death:
- Failure to act on Steven’s alerts: The alerts Steven made were not monitored or responded to appropriately.
- Lack of support provided by the local authority: Support should have been provided by the local authority on a weekly basis, though Steven stopped these visits. The local authority failed to maintain contact in spite of the cessation of visits.
- Failure to investigate or identify potential abuse: Despite his increased engagement with healthcare professionals and his increased visibility though services, there was a failure to investigate or identify potential abuse.
- Lack of information sharing with the police: Steven presented at the local hospital with injuries, stating he had been assaulted though this was not reported to police.
- Failure of local authority to safeguard Steven: Nor did they recognise he was at increased risk of abuse and neglect.
Actions for improvement
Following the SCR, the following improvements and actions have been taken to improve adult safeguarding practice:
- Improved systems of information sharing and reporting, encouraging a rapid response.
- Development of police and ambulance systems to indicate when there are repeat calls from the same people. This enables information to be shared between relevant agencies to develop appropriate, comprehensive responses.
- Increased awareness of agencies to be more responsive to signs of suspected abuse where the adult is at risk because of a pre-existing condition. In Steven’s case this was his learning disability.
