Torture murder victim Jimmy Prout went to hospital with with injuries just three months before his death, but medics did not raise concerns he was being abused.
The 43-year-old was subjected to a campaign of horrific violence at the hands of killers Zahid Zaman and Ann Corbett, before he was eventually killed, in 2016.
Zaman and Corbett were both jailed for life for murdering Jimmy at the home they all shared, in Percy Main, near North Shields.
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And now a Domestic Homicide Review (DHR), which explores the circumstances surrounding Jimmy's death has been published.
The report details a string of missed opportunities to identify Jimmy as a victim, and outlines seventeen key findings where things had gone wrong for Jimmy.
The review also describes how when Jimmy attended and was seen by doctors, one or more of the perpetrators went in with him when he was seen by medics, and attempts were not made to speak to him alone.
Shockingly in November 2015, just three months before he died, police were contacted by a hospital after Jimmy attended with four stab wounds, including one to his scrotum, extensive bruising and a dislocated shoulder.
But no social service referral or assessment of his risk of domestic abuse was made by either Northumbria Police or the hospital
Then at a GP appointment later that month Zaman did most of the talking for Jimmy, and the doctor did not ask to see the patient alone.
Today, North Tyneside Council, Northumbria Police, Northumbria Healthcare NHS Foundation Trust and the Safer North Tyneside Partnership, all say lessons have been learned from Jimmy's tragic death and that they have already begun implementing the series of recommendations made in the report.
And Paul Hanson, Chief Executive of North Tyneside Council has admitted that if agencies had communicated better, it's possible Jimmy could have been protected from his killers."
But Jimmy's heartbroken brother has slammed the professionals who he believes missed vital chances to stop the murder.
And Eddie Prout has told of his belief that Jimmy, who suffered from learning difficulties, was not thought to be at risk because he was an adult man who had a criminal record.
Eddie, 58, said: "There were a lot of missed opportunities. My brother could still be sitting here with me today. That breaks my heart.
"He attended hospital with all kinds of injuries. That should have rung alarm bells. I'm no doctor, I'm no professional, and I have no qualifications but if I saw somebody in that state I would have intervened. How come nobody picked up on it? How did this happen?
"He has just been brushed under the carpet because he's a man with a criminal record. Everyone jumped to conclusions about him."
Jimmy's murder was one of the most shocking and violent crimes our region has seen in recent years.
The vulnerable dad, from Scotswood in Newcastle, was subjected to repeated and grotesque abuse in the run-up to his death at Zaman's house on St Stephen's Way, in Percy Main.
Newcastle Crown Court heard how Zaman cut out one of Jimmy's testicles and forced him to eat it, knocked his teeth out with a hammer and chisel and forced him to have to sex with a dog.
Jimmy died on February 9, 2016, and his body was discovered more than a month later after it was dumped on wasteland near the Tyne Tunnel.
The court heard how disabled Zaman was the leader of a cult-like group of women, which included Corbett, Kay Rayworth and Myra Wood.
The report also tells how police were called to the house a number of times, and for various reasons before Jimmy died.
But Eddie believes because his brother was a man, he was not seen as a victim.
"It didn't cross their minds that he was a victim," said Eddie.
And he says there is nowhere for male victims of domestic abuse to seek help.
"The police went to the property where Jimmy was living on a number of occasions, for domestic violence," he said. "But every time the police were called he was treated as the perpetrator.
"They have got so many things in place for women who are victims of domestic violence, but what about the men? They have got safe houses for women, where are the ones for men? If Jimmy had wanted to get out of there where would he have gone. There is no information out there for men. Society needs to change. They are giving women a licence to kill."
"In my mind he was a child because he only had the mentality of a child. Surely the police must have known that he was getting abused. But why didn't they remove him from that situation and put him somewhere for his own safety."
"Basically they must have thought; 'It's only Jimmy Prout, he's a rogue.' That's my opinion. They just didn't care.
As Jimmy's abusers stood trial the jury were shown CCTV images of the frail victim being dragged around by his tormentors.
Jimmy looked painfully thin and disorientated in the pictures.
And Eddie believes passers-by simply turned a blind eye.
"If I seen someone like that I would do something. Someone must have heard Jimmy crying or screaming," he said. "But I think people round there were terrified of Zaman. Some said they were petrified to come forward when the investigations were going on because of the repercussions.
"He had a hold over a lot of people.
Eddie has spent the past seven years pushing for the DHR to be published as quickly as possible in the hope that lessons learned from the review will help prevent others suffering the same horrific fate as his brother.
But seeing the events leading to his brother's death outlined in black and white has been bittersweet for him.
"If just one person had intervened things could have been different," said Eddie. "If this prevents this from happening to any other family at least Jimmy has achieved something.
"I will be happy if lessons are learned, but nothing will ever bring my brother back."
Paul Hanson, Chief Executive of North Tyneside Council said: "On behalf of North Tyneside Council, I would like to pass on our deepest and most sincere condolences to the family of Jimmy.
“The people responsible for the hideous murder have been served justice in our courts. The people Jimmy thought were his friends, controlled him, manipulated him and harmed him. They did this in an evil, calculated way and they knew the approach they were taking would stop Jimmy getting the help and protection he needed.
“We welcome the findings of the review and we have already completed work on the recommendations. I accept that if services had communicated more frequently, through the right channels, a greater picture of Jimmy’s life could have been painted. This more complete picture might have provided us with a greater chance to protect Jimmy from the people who murdered him.
“We will continue to work together to make sure North Tyneside is a safe and caring Borough. We will continue to do our best so our communities recognise the warning signs of abuse and controlling behaviour, so they can report safeguarding concerns.
“Please, if you see something, say something”
And Paula Shandran, associate director of professional standards and safeguarding at Northumbria Healthcare NHS Foundation Trust, said: “The report gives valuable insight into learning, which we have already shared across our trust, and in relation to further improvements we can make. We are already implementing these improvements and they include mandatory domestic abuse training for staff, focussed on male victims too, and we now have a dedicated domestic abuse specialist practitioner.
“We closely monitor when patients with potential safeguarding issues miss appointments or decline intervention and support. We are absolutely committed to working in partnership with other agencies which is crucial to continue to protect and look after vulnerable patients.”
And Chief Supt Lyn Peart, Head of Northumbria Police’s Safeguarding Department, added: “First and foremost, our thoughts continue to be with the loved ones of the victim following his tragic death.
“This was an extremely complex and challenging case for everyone involved which resulted in a number of people being brought to justice.
“This finalised report highlights the valuable lessons all agencies have learned following this tragedy.
“Northumbria Police did not wait for the publication of the report to start implementing the recommendations highlighted, and these have now been in place for some time.
“Protecting those who are vulnerable is our number one priority and we will continue to work with our partners to keep our communities safe.”
A statement on behalf of the Safer North Tyneside Partnership, which conducted the review says: "This was an extremely complex and challenging case for all agencies involved, we hope this finalised report highlights the valuable lessons all agencies have learnt. We would like to make it clear, when our agencies can work together better, we will.
“All partners have acknowledged this report and are already well underway with implementing all recommendations highlighted in the Action Plan and Executive Summary.
"This Includes communicating more clearly, building on their strong partnerships and to view vulnerable residents in an open and holistic way, across multiple agencies, protecting them at every point the have contact with a service.
"Although this report has taken time to be published, we have not sat by and waited for the recommendations to be finalised; where changes can be made to better protect our residents and communities we have moved quickly and done just that.
“All partners represented on the board are committed to keeping residents and patients, especially those most vulnerable, safe.”
A spokesperson for NHS North East and North Cumbria Integrated Care Board (ICB) said: "We wish to share our deepest sympathies with Jimmy's family and friends. No-one should suffer in the way Jimmy did.
"This was a highly unusual and complex situation, in which Jimmy's abusers deviously controlled him while pretending to care for him. But it is clear that there were opportunities to identify signs of abuse, and for services to link together more effectively in offering support.
"Soon after Jimmy's tragic death, North Tyneside CCG [which was replaced by the ICB in July 2022] and its local partners took a series of steps to ensure the voice of the victim is heard, and improve the way we recognise and respond to unusual and complex cases of domestic abuse, coercive and controlling behaviour.
"This included improving the existing domestic abuse pathway, diagnosis and coordination between agencies. GPs and their teams in North Tyneside and the North East now have enhanced training in ensuring victims' voices are heard, as well as understanding factors like controlling behaviour, applying chaperoning policies and greater understanding that perceived perpetrators may actually be victims, needing protection from abuse themselves.
"Extra training and support is also helping GPs to identify, diagnose and support patients who might have a learning difficulty."
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