Today, 17 September 2013, two serious case reviews are published, one into the death of four year old Daniel Pelka who lived in Coventry and the other into 81 year old Gloria Foster who lived in Surrey. This post will introduce serious case reviews, introduce Gloria, précis the circumstances around her death and discuss societal attitudes to the death of vulnerable adults. It will not lay blame and it will not seek to share all of the points to learn, each serious case review contains clear recommendations and they are linked at the end of the post.
What is a serious case review?
A serious case review (or SCR) is conducted when an at-risk child or a vulnerable adult dies and abuse or neglect are expected to be a factor. SCRs are not about apportioning blame or identifying who is culpable, that is the work of the Police. Serious case reviews are held to identify the circumstances of a death and identify lessons to be learned to prevent others suffering the same experience.
Who was Gloria Foster?
Gloria Foster was born in India in 1931. She spent her childhood there moving to England when she was 16 in 1947. Gloria worked for Shell as a company secretary living in Canada and Nigeria and it was through her work that she met her husband Bob. They married in 1971, but less than two years later tragedy struck when Bob was killed in a road accident in Tehran. Gloria was described as ‘fiercely independent’ and ‘a full and reflective character. People enjoyed her company. She enjoyed the theatre and was a big social lady’. This is someone who made the most of the cards she was dealt in life.
Friends described her as busy and active enjoying ‘travel, bridge, the theatre, tennis and other sports’. She was also a one time member of a bowls club and a golf club ‘a keen sportswoman, dog lover and bridge player with a big circle of friends at the golf club’. I think it’s fair to assume that Gloria Foster was a character and someone who enjoyed life, a gregarious person who would sit down and chat with anybody.
So what happened?
Gloria Foster was diagnosed with anxiety and depression in the late 70s and vascular dementia five years ago and she was hospitalised following a stroke at the end of 2011. Friends report that she lost confidence and grew increasingly reclusive. She had been receiving a care package from the agency Carefirst24 since September 2007. She received four visits a day to provide support with personal care, medication and nutrition. This appeared to be working well, although regular reviews by Surrey had been overlooked. There was nothing to suggest that the care Mrs Foster received from the care agency, her GP or District Nursing staff was in any way deficient.
On the 24th November 2012 a whistleblower alleged illegal working and practices at Carefirst24. What then happened was a number of small scale mistakes that led to catastrophic circumstances. Investigations were conducted and early 2013 saw ‘substantial coordination activity between the London Borough of Sutton (where Carefirst24 was registered), Care Quality Commission (CQC), UK Border Agency-Home Office, the Metropolitan Police and Surrey County Council’. On the 15 January 2013 a planned raid took place, Surrey and Sutton Councils had already successfully made arrangements for the changeover of support from Carefirst24 to other agencies for the individuals whose support they were paying for. By midday on the day of the raid a list of self-funders purchasing support from Carefirst24 was made available. It was at this point that Gloria’s story takes a tragic twist. A member of staff was requested to contact those on the list to offer support, advice, information and a list of alternative providers, so that alternative care arrangements could be put in place. Gloria was missed. It is still under dispute whether a call was made, but she did not answer the phone, and no-one contacted the person with power of attorney for her.
Gloria was simply forgotten. She had received her last visit from a support worker on the 15th and it was nine days later on 24th January, shortly after 10am, when Mrs Foster was found by a District Nurse:
…in a very poor physical state. She was cold, lying partially off her bed which was sodden with urine and faeces and she appeared dehydrated with cracked lips. The ambulance crew were unable to record a blood pressure or find a radial pulse (wrist) indicating that her blood pressure was extremely low.
Gloria Foster was admitted to hospital where she received emergency treatment, her condition appeared to be improving but at 07.45 on 4th February she died.
So what are we meant to do about it?
I’ve read enough serious case reviews and executive summaries to warrant sleepless nights if I spend too long thinking about them. On this occasion it sounds like a truly tragic set of circumstances, as Vic Citarella, author of the report states ‘A serious mistake seems an inadequate description of what happened. But leaving aside all the ‘what ifs’, that is exactly what happened’. There were some serious omissions and some serious errors of judgement, including the belief that because someone was self funding they would be able to arrange their own care. There are a number of recommendations made for local authorities and those working with vulnerable adults, but before we jump to blame ‘the system’ what can we do?
My view is that there is enough evidence out there, it is about using that evidence differently. Two years ago after Winterbourne View broke in the news I wrote this and my personal view is that we know what needs to change, there just appears to be a societal lethargy when it comes to vulnerable adults. This isn’t simply a problem for those who work in social care or health to address, this is about our underlying beliefs, concerns and behaviours as a society. With a particular focus on what the media feeds us.
So what does the media feed us?
Before we go any further I am keen to point out that I am not comparing Daniel Pelka and Gloria Foster to make some point about child abuse receiving too much attention. I don’t think that’s the case at all. I do think that abuse of vulnerable adults receives woeful amounts of attention and I hope that by drawing the information together in this way it serves to illustrate a couple of points.
Let’s look at the graph though. First thing I’ll draw your attention to is that Daniel is at the front end of the curve. He’s young, has his whole life ahead of him. He starved to death, while under the ‘care’ of his mother and her boyfriend. He was four years old. Today at 7pm Daniel had 87 BBC news stories about him (including 15 TV and radio programmes) and almost 6k tweets shared in the last 30 days. This was a search of his name so excluded related hashtags or tweets just mentioning his surname.
Compare this to Gloria. She is towards the end of that curve, was 81 years old, had 12 BBC news stories about her, no TV or radio mentions, and barely only 350 tweets. There was no hashtag for Gloria so I started one this morning #hernamewasGloria but it has yet to take off!
It appears to me that we have a bit of an issue in society. The outrage when a child dies I completely comprehend. The absence of coverage and almost indifference to the death of an older person makes no sense to me.
How have we become a society where someone receives no calls, no visits, and is not missed for nine days. Worse still how are we living in a society where people just accept that?
Today I’ve tried to share a bit about Gloria, to bring her alive to people, to acknowledge her narrative. I hope that by reading this you will have taken a moment to remember Gloria, to think about the implications for yourself and consider our culpability as a society that this can happen. Sure, it’s easy to blame the people involved, of course they could and should have done differently. Mistakes happen though and I believe that it is up to each and every one of us to take some share of responsibility for creating a society where this can happen.
The SCR into Gloria’s death lists a number of recommendations and learning points, not least a real wake up calls for all local authorities who let’s be honest, don’t really know what their self-funder market looks like. This could have happened anywhere, and to some extent it’s a credit to agencies working together that more people weren’t affected. That aside, what are we going to do to ensure that we share some responsibility? The serious case review report concludes with the statement that ‘Surrey Safeguarding Adults Board will do well to give Mrs Foster a practical and positive legacy by demonstrably learning the lessons that have emanated from this serious case review‘. I think it’s time for us all to step up, we should each be working together to build that legacy and ensure that those in need in our society are not left to fend for themselves.
Say hello to your neighbours, make a call if you’ve not seen carers visiting for a while, throw off the Great British affliction of ‘not being nosey’ and start caring and taking responsibility for those who live in our neighbourhoods. We owe it to Gloria Foster to make sure we do that.
All of the direct quotes from the serious case review into Gloria Foster’s death that you can access here Gloria Foster Serious Case Review. You can also visit the website for Surrey Safeguarding Adults Board or read the Daniel Pelka Serious Case Review and visit the website of Coventry Safeguarding Children Board.