Her name was Gloria

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? 


Daniel and Gloria

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!

So what?

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.


11 comments on “Her name was Gloria”

Eddie Clarke says:

Well said. Points very well made. As you say, it’s not about comparisons with child abuse. It’s about respecting and valuing older people. If we don’t care for others, then what/who are we? Self interested, self centred individuals. Similar things could be said sometimes about the care received by people with a learning disability. For example, Six Lives, with the roots going back to Ely Hospital and beyond. All respect to Gloria and her life.

george says:

Hi Eddie, thanks for commenting. It is really sad that in some regards we have travelled such little distance since Ely. Small steps though, hope that this post will make a few people think about how we are all responsible and what little thing we can each do to improve someone else’s existence. Maybe.

Boxerdog says:

Yes all power to your elbow. You are right to draw these 2 events together as a way that the media decide what’s important and then feed the public with “productive” news, i.e. news that encourages the public to engage with the media who can then expose them to other saleable stuff.

It promotes inequality, by deciding who is worthy and who isn’t and this gap just doesn’t exist between young and old, when it comes to news of abuse, there is inequality between victims.

I have been trying to tell the story of extremely vulnerable children physically and sexually abused in a residential school in the 1980’s and 90’s. I have written to all the major news media, M.P.’s, Agencies like the NSPCC etc, and the Local Safeguarding Children’s Board…..and no takers despite the fact that 2 of the perpetrators have already been convicted of a number of offences and they are now facing more after the original cases were publicised in the local press.

I blew the whistle on these men in the 1980’s only to be told that I was talking rubbish, and I was forced to leave my job as a newly qualified social worker, whilst the perpetrators were kept on. But ever since that gurning gargoyle Savile became front page news you can’t get a story of sexual abuse in the national press unless a) it involves a celebrity b)it has the patronage of a celebrity or c)has some vested interest by a particular news agency, e.g the story of children abused by monks in Scotland….. a story which was broken by the BBC during a piece of investigative journalism.

So as you can see in the 21st century we have become so sophisticated that inequality even infects the victims and their families in child and adult abuse.

John Donne must be spinning in his grave because his fine words…..”any mans death diminishes me because I am involved in mankind, therefore never send to know for whom the bells toll….it tolls for thee”, are largely moribund in modern Britain……so it goes

P.S. Ever since my failed attempt at whistleblowing I have made a study of the literature of abuse and dysfunction in social work and other caring agencies, in relation to both children and adults. The key features being human incompetence, human deviance,
organisational structures, the low value of direct work and deliberate wrongdoing. All human flaws well catalogued and recorded in all our literature so that they are obvious to even an untrained eye, but the big people who can change things have the telescope to their blind eyes, and choose to blame the easy scapegoats

sorry for ranting but I believe that social work is broken beyond repair

george says:

Thanks for taking the time to comment Boxerdog, and please don’t apologise for ranting. In my opinion you not only bring to the table yet another perspective on why we all need to take responsibility, but you also introduced that John Donne quote that has got me thinking ever since. It’s really powerful, thank you. As for social work being broken, you’re certainly not the first social worker to say that to me of late, I guess what I was hoping for from this post was to a) raise people’s awareness and b) consider humanity and our role within it, so whether social work is broken or not there may still be some hope for us all. Thank you so much for commenting.

Thanks once again for this George. I am still not rational enough to comment, but I feel compelled to do so.

Here in NI, there are yet more stories in our news today about neglected children and older adults, failed by the “system”. I understand that the gist of your article was to draw attention to the human plight of Gloria and our collective responsibility as a society.

I don’t profess to understand the workings of social care in England – as it is different in NI. And of course, I understand that by looking at blame, I am really just trying to create some logic to explain it all. But the whole story, from her initial demise through anxiety and depression, and then into dementia seems that many opportunities were missed by family, friends, health/social care and neighbours in society to help support this lady in a better quality of life. So I am not just looking at the cause of this story – the error by the care agency re-allocation, I am wondering why no-one thought to check on this lady after 9 days. Why was she not on some sort of risk register, like they have for vulnerable children? The college of social workers said she had “complex needs” – if that was the case, why wasn’t more attention paid to her? To have someone as vulnerable as this only served by one agency, seems inappropriate. Where were the system checks and balances?

Even as I type this I still feel so angry for Gloria. I don’t want to go to the place where I am thinking about her in her home alone in those conditions, but it is hard not to. In my mum’s illness, we had a similar progression – withdrawal, social isolation and difficulty accepting help. But with a set of extended friends and family, we coped. We looked into various care options, such as residential homes, but frankly, they were mainly depressing. It seems that we need to re-think our care arrangements for older people, who have specific health and social care needs. In NI we have some assistive housing schemes, called “The Fold”. Older people who need assistance can live fairly independently in adapted bungalows, but have daily help and access to emergency aid if needed. They provide a good sense of community, while also encouraging and providing different activities such as light gardening or painting classes. I’d like to see more of these types of housing and community schemes. We need to start getting more creative about how we care for our older people who may or may not have complex health and social care needs. Frankly, our narrative around growing older needs to change – never mind the narrative around older person’s illness and disability!

What is happening in society when someone like Gloria, who led a fantastic life, is allowed to face this sort of death? We have allowed Gloria’s story and legacy to be lost amidst a bureaucracy of futile paper work and over burdened staff.

I’m not offering any solutions here I know, but once again, thank you sincerely for drawing this to our attention.

May Gloria rest in peace and be in a much happier place than she was in during her last few days.

Best wishes,

george says:

Thanks for commenting here and discussing on twitter Fiona, your thoughts have been useful probes for further reflections of my own. Particularly like your comment about blame as some sort of way of sense making/logic finding – is a useful, and far more positive interpretation than I had originally thought, which was simply about sloping shoulders/pointing fingers to distance oneself from the horror of the reality.

I think (from your comments and a couple of others on twitter) that I may have misrepresented this a little. Gloria had a fabulous friend who acted as her Power of Attorney who had visited the same day that the care worker last visited – this wasn’t someone who was entirely isolated and abandoned, indeed she had many people who cared about her and I suspect that is the only reason that her SCR has received any attention at all. The question you raise about risk registers comes back to a complicated point about her self-funding her own care and where the LA responsibility lines are drawn and the mistaken belief from the social worker that ‘because she was funding her own care she could arrange her own care’ – grossly inaccurate and ultimately poor practice. Of course you’re well aware of the shockingly bad response from BASW to this situation because you’ve seen it unfold on twitter (no press release/a website article in the Huffington Post pushing their own agendas and failing to acknowledge the social worker error in this case/zero engagement with those asking questions of them) but you could argue it neatly reflects part of the problem – poor social work leadership.

Ultimately my post was trying to avoid laying blame, and seeking to prompt us all to consider our responsibilities. I didn’t do it as well as I’d hoped because a few people mistook it for me suggesting ‘neighbourliness was the solution’, it may be part of it, as would alternative living arrangements (check out Shared Lives for another option) but it is not what ultimately happened here, which was an error of judgement by a senior social worker. Thank you for engaging with it and sharing your own experience. I hope to blog more about living arrangements in due course…watch this space.

Edna says:

The great enemy of the truth is very often not the lie — deliberate, contrived and dishonest, but the myth, persistent, persuasive, and unrealistic. Belief in myths allows the comfort of opinion without the discomfort of thought. John F. Kennedy 35th president of US 1961-1963 (1917 – 1963)

It seems social work exists on a belief in myths, and clearly those who make their living from the social care system do not want to know how their lies etc. contribute to the myths that are perpetuated.

So sad you cannot publish a fact- it speaks volumes and explains why this broken and unrealistic system will be its own downfall. We reap what we sow.

george says:

Hi Edna, not sure whether your comment was referring to me not publishing a fact (I have one comment I did not publish because it was left anonymously with a false email address) or is a greater reflection on the way the case was handled, but thanks for taking the time to comment.

Lorna Prescott says:

Thanks for sharing some of Gloria’s story – this does feel important to know. Having read your post I was left wondering about Gloria’s large circles of friends, rather than focusing on what happened in the care system. I started to ponder whether it could be a disadvantage to be an outgoing, easy to get along with person who has lots of friends from the point of view that when you then become ill or something, it’s easy for everyone to assume someone else will be looking out for you. And if everyone assumes that …
We will probably never have a way to know, but I wonder whether any other Glorias out there have been prevented from being in the situation that she was thanks to a caring friend (maybe a grown-up child of someone her age). We struggle to take on the power of players in the system, for reasons described by commenters above. However we can use our own power to care for each other, we’re just not always great at that either. Do we need to hear more about people who do it well to inspire us?

george says:

Thanks for reading, sharing and commenting Lorna. I fear I may have misrepresented Gloria’s case a little – she had very good friends, who took an active role in her life, in fact one was her Power of Attorney and had been to visit the same day as the care worker last saw her. Gloria’s story was particularly striking for me because her earlier life reminded me of one of my Mum’s closest friends, a much loved lady who developed dementia in later life and ultimately moved to a brilliant care home to live when her own husband died. Her daughters both live overseas and have always acknowledged the support and friendship my Mum provided for their Mum (and indeed them). I guess luckily for all of us this lady had previously worked with my Mum and provided her with much support and worldly advice earlier in life (no doubt some of it about how to handle adolescent daughters) and so really I think that it felt like repaying that from my Mum’s perspective – I guess that’s what friendship is all about, so maybe the focus should be on how we support communities and people to connect and form strong connections earlier in life so that those networks exist when support is needed.

It makes me feel a bit empty to realise we’re talking about how to connect humans to each other, have we really developed to a point where we’ve forgotten the basics? More blogs to follow on this am sure 😉

Ann Penston says:

I have only just discovered this website via a friend. I was one of the Enduring Powers of Attorney for Gloria Foster (that is a restricted POA in that we only had authority over her finances) and dealt with the media. There was a lot of BBC national news and BBCSurrey coverage of the story and on the ITN news. The story was also covered by Sky witnessed by the fact that I had friends calling me from South Africa and Spain asking about the events. Also these days the internet replaces some of the traditional news forms.
In respect of friends, family etc. Gloria turned people away from the start of her illness in 2007 – they didn’t dessert her, some even turning up at her door but being made very aware by her she wouldn’t invite them in. That is something I want to be made very clear.
I believe with the various cases this year – Mid-Staffs and the various care homes – the elderly cases are getting more attention and The Daily Mail is running a programme Dignity for the Elderly, highlighting neglect of the elderly.

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