Agencies failed Blackpool woman starved to death by mother - report

A woman with Down's syndrome who was starved to death by her mother was "failed" by all agencies involved with her family, a review has found.

Debbie Leitch's mother Elaine Clarke was jailed after the 24-year-old's emaciated body was found in 2019.

A review said she was "neglected from birth", but agencies were "not always aware of this" as she moved from East Sussex to Leeds and on to Blackpool.

Blackpool Council said changes had "already been implemented".

The review, which was commissioned by Blackpool Safeguarding Adult Boards following Clarke's sentencing in March 2022, found professionals working with Ms Leitch were "not always aware" of her circumstances due to her family's relocations and Clarke being allowed to convey her daughter's "wishes and feelings".

"Consequently, [Ms Leitch] was not heard, and [Clarke] made her decisions," it said.

It said that while such a situation was "legally acceptable" when Ms Leitch was a child, decisions made once she was an adult "should have been decided using the best interest principle".

'Lost in the system'

It said "no information regarding [her] care needs or circumstances was communicated from Leeds to Blackpool" when the family moved in 2016 and "occasions for agency intervention", such as when Ms Leitch had a skin condition or when there was a "domestic incident", had "created opportunities for cross-border discussion" but they had "not ensued".

The "dangerous" omission meant knowledge about the neglect could not be used to inform her risk management and support, it said.

It also said all agencies involved with Ms Leitch, including her GP, a local hospital and the police, did not apply a "whole family" approach, which meant "opportunities were missed" and information "was not shared effectively".

The review said "miscommunication and presumptions" left Ms Leitch "unsupported, invisible, and isolated"

It said a family member's report about Ms Leitch being neglected in 2019 to Blackpool's children's social care team, which was referred on to adult social care, had "proved ineffective as it got lost in the system" and the information the latter team received was "in comparison, diluted" and "diverted" the team to focus on her health.

It said that the "miscommunications and presumptions" left Ms Leitch "without professional safeguarding support" for a further six-day period and by the time a social worker visited, Clarke had "tidied the house to an acceptable state".

"Consequently, following the social worker visiting and not having any concerns, [Ms Leitch] was again left in the care of Clarke - unsupported, invisible, and isolated," it said.

The report concluded there was "no doubt" Ms Leitch was "failed and unless the learning of this review is used to develop practice, the same outcome could befall other adults at risk".

Karen Smith, Blackpool's director of adult services, said Clarke had "manipulated circumstances so her neglect was not apparent to ourselves and other agencies".

"However, it is clear from the review that there were missed opportunities and [Ms Leitch]'s voice was seldom heard," she said.

"[Her] tragic death has taught us a lot and changes have already been implemented."

The BBC has contacted Leeds City Council, Lancashire Police and NHS Blackpool Teaching Hospitals for comment.

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