Vulnerable Upminster woman not protected at night before son killed her, coroner says
PUBLISHED: 19:30 03 June 2020
A coroner ruled a vulnerable woman killed by her son at their Upminster home was not protected at night-time.
Verdicts were made in the inquests of Vera Savage, 89, and her son John, 54, who were found dead in the bathroom at their Blyth Walk address on July 10, 2017.
In a virtual hearing from Walthamstow Coroner’s Court this Tuesday (June 2), senior coroner Nadia Persaud gave a narrative verdict on Vera’s death and said she had been unlawfully killed.
She died sometime between 11pm on July 9 and 9.30am on July 10.
Ms Persaud ruled John’s death was suicide.
A carer visiting on the morning of July 10 found a note stuck to the door at the Savages’ home, which read: “12 Blyth Walk, 9th July, 2017. Suicide. Call police. Side gate unlocked. Back door unlocked. JS. Call police.”
The court was told further notes written by John were found inside the home.
Ms Persaud said: “Mr and Mrs Savage were both vulnerable adults in need of support and protection from public services. They were dependent on each other financially and emotionally.”
She added: “I am satisfied beyond reasonable doubt that Mr Savage took the life of his mother and, after doing this, he took his own life.”
But she said a verdict of unlawful killing in the case of Vera would have been “verging on misleading”.
The hearing had been adjourned in October last year for the coroner to seek an independent expert witness to assess the case.
Keith McKinstrie, who has previously completed independent reviews, gave evidence last Thursday (May 28) giving his opinion on the service provided by Havering Council.
He told the court it was “inexplicable” the council failed to contact John’s close friend and Vera’s deputy power of attorney Darren Carmichael, neighbours or carers when concerns were raised.
Mr McKinstrie listed a number of criticisms of the way in which the issues were handled.
Ms Persaud described how a “catastrophic chain of events” began when mother and son were defrauded out of £50,000 by a builder in November 2016.
Vera and John had lived together for more than 50 years and were co-habiting alone since the death of Vera’s husband Reg in 2005.
John’s cousin Sally Welsh told the court the pair had become “reclusive” since his death while Mr Carmichael said the fraud “really broke” John.
Mr Carmichael also said John, who he had been friends with for 25 years, suffered from “horrific” sleep deprivation.
The court previously heard John struggled to care for his mother while Ms Persaud said he was dealing with depression, mental and behavioural disorders due to alcohol abuse and may also have had obsessive compulsive disorder.
The court was told that John attempted suicide in February 2017 and was then sectioned and placed at Goodmayes Hospital, run by North East London NHS Foundation Trust (NELFT).
NELFT mental health nurse Colin Clancy assessed Vera and believed John would “eventually kill himself and may kill her too”.
But the court heard this was not included in John’s records.
Vera was placed into a care home and then returned to her Upminster home in March.
The court heard from Mr Carmichael that John “feared homelessness” and was worried that if Vera went into care, he would lose the home.
Concerns were also raised by the Savages’ next-door neighbour Paula Winter.
From November 2016, she said she heard screaming, shouting and banging coming from the property during the night and called police on one occasion.
She emailed Havering Council in March and wrote: “I’m seriously concerned about what he (John) might do to either himself, his mother or even someone else.
“At times he sounds like he’s going to seriously hurt his mother and I have heard him threatening to kill her on several occasions.”
She again contacted the council in April with further reports of “screaming and shouting”.
But she told the court that on neither occasion did the council follow up to obtain more detail.
A section 42 enquiry threshold was deemed to have been met at the end of March - where local authorities must make enquiries or tell others to do so if it believes a person is being abused or neglected or is at risk.
But Mr McKinstrie said no progress was made in this before it was agreed the threshold was met again in July - he said an investigation should have happened earlier.
The court heard that social workers visited the home on May 25, 2017 and one said John may be “neglecting” himself.
Mr McKinstrie said they did not quantify the risk posed to Vera by the possible deterioration of John’s mental health.
On May 31, 2017, Mark Laporte, a builder working on an extension at Ms Winter’s home, called police after hearing a disturbance at the Savages and thought a woman was being attacked by a man.
The court heard the council moved her into the Oaks Care Home in Upminster as an emergency respite placement in response to this incident where she stayed until June 28 when she was discharged home.
Mr McKinstrie said the issue of Vera’s capacity to make decisions was crucial and he said there were indications in her time at the Oaks that she lacked capacity.
Once she was discharged, carers were assigned to visit three times a day and health workers told the court of their concerns about the living situation.
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Carers Ceri Sturgeon and Sharmin Raz, from agency Carewatch, recalled seeing Vera with large unexplained bruises on her arms, legs and nose.
Carewatch reported concerns to the council on July 6.
Mr McKinstrie felt at this point there was a “building picture” and an escalation of risk.
He said discussions could have been made with John and Vera, who had an informal dementia diagnosis, to return her to the Oaks while investigations were made.
Dr Erin Butterworth, Vera’s GP, also rememebered seeing bruises on Vera’s shins during a visit on July 7.
Mr McKinstrie found no risk assessment was made at any point between November and their deaths, adding the high risk to Vera at night should have been apparent.
On making the findings of fact, Ms Persaud said there was “inadequate” focus on the risk posed to Vera before John’s discharge home from hospital in February 2017.
She said NELFT failed to pull together all of the information in March and April on John’s risk to his mother.
She criticised the council’s response to concerns raised by Ms Winter and said a risk assessment and protection plan should have happened after the neighbour submitted her concerns.
Ms Persaud described a visit on March 31 of a manager in the council’s adult community team south at the time to the home as “wholly inadequate” and said basic steps such as speaking to Ms Winter and reviewing Vera’s records were not taken.
She said NELFT’s home treatment team should have discussed a protection plan for Vera with the council after their assessment on April 6.
A referral to a multi-agency risk assessment conference (MARAC) or a formal multi-agency meeting should at least have happened by the end of May, the coroner said.
Ms Persaud told the court that the social worker’s report on May 25 of John “neglecting” himself should have raised concerns of a possible deterioration in his mental health.
She also said there were inadequate moves while Vera was at the Oaks to formally assess her mental capacity and to fully assess her risk of returning home with John.
The coroner had no concern relating to the actions of police in the Savages’ case.
Ms Persaud said: “The protection plan of carers three times a day, during the day, was insufficient to meet the risks apparent in this case.
“The history required steps to be taken to attempt to minimise the risk at night. No steps were taken at all to address the risk during the night.”
She added that the risk of John taking Vera’s life would have been “much reduced” if a carer had been in place at night.
“There is no evidence that Mr Savage and Mrs Savage would not have accepted a night carer. They were never asked the question. Care had been accepted in their home in March and June 2017.
“Night carers might have interfered less with Mr Savage’s routines. Night care would have permitted Mrs Savage to have the sleeping tablets that were given to her in The Oaks.
“If Mr Savage had been allowed to sleep, one of the stressors that led to his admission in February 2017 would have been removed.”
Giving the narrative verdict on Vera’s death, Ms Persaud said: “Concerns were raised about Mrs Savage’s wellbeing with the local authority in November 2016.
“Further reported concerns grew in their severity until March 2017, when concerns at this time included a threat to her life.
“Despite the seriousness of the concerns raised, there was no comprehensive risk assessment carried out and a fully informed protection plan was not put into place.
“A section 42 enquiry was commenced on March 31, 2017 as it was recognised that serious physical harm could result to Mrs Savage, however the section 42 enquiry was not completed.
“The mental health trust documented a risk to Mrs Savage’s life, but the risk was not clearly communicated between teams and this risk to Mrs Savage was not fully assessed.
“The night times were a time of heightened risk. There was no protection in place in her home address during the night-time.”
Ms Persaud acknowledged that the council and NELFT have taken action plans seriously since the deaths.
She said: “I am satisfied there has been wide ranging learning after these deaths. I am satisfied both organisations have taken action so far as they are able to.”
Councillor Jason Frost, the council’s cabinet member for health and adult care services, said the Savages’ deaths remain devastating to the council.
He added: “We express our deep condolences to the family and friends of Vera and John Savage.
“Any circumstances like the ones in which Vera and John died must be thoroughly investigated and reviewed so that we can understand what went wrong and what needs to be done differently to prevent something similar from happening.
“That process, featuring all relevant local partners, was started by the council and began even before the coroner’s inquest.
“The coroner has acknowledged that we have acted on all the key issues raised as a result of the investigations.
“This includes adapting how we manage risk assessment and mental capacity, as well as changes to our management of safeguarding adult work.
“We have improved our joint working arrangements with NELFT services so that where both organisations are involved with the care of a family such as the Savages, we share the right information to reduce any risks and to safeguard more effectively together.”
A spokesperson for NELFT said: “We would like to express our deepest sympathies to the family and friends of John and Vera Savage.
“We are not able to comment on individual cases but are determined to continuously improve the quality of care we provide to our service users and their families.
“Following the coroner’s report we have reviewed how we deliver safe and effective care and have implemented new ways of managing any risk to our patients. We also have improved the training we provide our staff.
“We’re working closely with our partners in the wider health and social care system to improve how we deliver joined up care and support, and continue the necessary work to improve our services for our patients.”
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