A string of missed chances to help torture murder victim Jimmy Prout have been highlighted in a report published today.
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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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.
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.
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.
The DHR concludes that Jimmy was abused in "plain sight" but alerts were not made to those that could have protected him.
The key findings in the report include:
-There were opportunities when safeguarding alerts could have been made after GP appointments, police interviews and visits to A&E, but no alerts were made meaning Jimmy did not have contact with social services himself.
-The perpetrators of the abuse used professional’s appointments and meetings to reinforce their control over Jimmy, and professionals did not ask to see him alone
The report says: "It is well documented that perpetrators of domestic abuse control their victims through following them to appointments and insist on attending appointments and it is therefore best practice to seek to speak to people alone whenever possible. This did not happen and as a result Jimmy did not have the opportunity to speak to professionals at any point during the timeframe of the review on his own."
-There was a lack of "clarity and urgency" in adult safeguarding arrangements, meaning Jimmy was not seen as a potential victim.
"The safeguarding response does not appear to have been effectively coordinated or overseen at a multi-agency level, and as a result, opportunities were missed to see Jimmy as a potential victim of abuse," the report says. "There was a confused approach to the implementation of adult protection arrangements. Signs that Jimmy was being abused and exploited were missed as a direct result of the late formation of safeguarding strategy meetings.
-People are viewed as either perpetrator or victim of abuse:
"Jimmy was not identified as a possible victim of abuse and exploitation. Jimmy was instead viewed as a perpetrator of domestic abuse, and this obscured services ability to see his vulnerabilities and that he was also a victim of abuse and exploitation," the report says. "There were indicators Jimmy was an adult at risk of harm, his presentation had deteriorated, he was dirty and dishevelled, he had lost weight, he had lost teeth, and he had visible bruising yet despite this his vulnerability as not recognized.
"No single agency had a full picture of what was happening in Jimmy's life and there were several missed opportunities for initiating safeguarding procedures, assessments, or other interventions and for agencies to share information.
"Jimmy was not considered vulnerable or at risk of harm as services viewed him as a perpetrator of domestic abuse rather than a potential victim."
-Services were not aware of the impact of trauma:
Jimmy was viewed as a man who did not engage with services instead of a man who wanted to engage with services but was afraid.
"Jimmy couldn’t speak out as he was too afraid of the consequences," the report says. "Even towards the end of his life, when his physical condition deteriorated, trauma and fear prevented him from speaking out."
-Professional curiosity was lacking across all agencies:
The report says: "Professional curiosity is the capacity and communication skill to explore and understand what is happening with an individual or family. It is about enquiring deeper and using proactive questioning and challenge. It is about understanding one’s responsibility and knowing when to act, rather than making assumptions or taking things at face value. Sadly, across all agencies who took part in this review very few examples could be found of agencies looking beyond what was presented to them even when at times the presentations were highly unusual. This is a recurring theme both locally and nationally across all safeguarding reviews."
The report makes a number of recommendations to prevent others suffering the same fate as Jimmy
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.
He said: "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”
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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