A damning report says safeguarding agencies failed a vulnerable woman who was starved to death by her mother after years of neglect.
Elaine Clarke is currently serving a lengthy prison sentence for causing the death of her daughter Debbie Leitch, 24, who had Down's Syndrome. Clarke starved her daughter whose emancipated body was found in a filthy bedroom covered in takeaway boxes and used nappies at their home in Blackpool in August 2019.
Clarke, who had previously lived in Leeds with her family, later admitted manslaughter at Preston Crown Court and was locked up for nine years and seven months. A safeguarding review has now identified a catalogue of failures and found that agencies let Debbie down as they were "not always aware" of the neglect that she was suffering.
Read more: Tragic case of Leeds teenager whose death remains a mystery over 30 years after body was found
The report said the mum managed to hide the abuse by moving multiple times and by speaking for her daughter when she shouldn't have been allowed to. As Debbie was an adult, she should have been able to have a say in her wishes but was denied this right by her mother.
The review said: "Instead of finding a way to communicate directly with Debbie, professionals relied on Clarke to speak on her behalf. Professionals needed to communicate with Debbie alone and consider her decision-making capacity.
"Debbie's voice was inaccurately represented when she was not presented for health appointments as her records showed that she ‘Did Not Attend.’ Yet Debbie lacked the physical ability and/or mental capacity to attend, or make the decision to attend, appointments."
The report added: "A more accurate description of Debbie not being present for appointments would be to record that she ‘Was Not Brought.’"
The review, commissioned by Blackpool Safeguarding Adult Board, revealed that the loss and miscommunication of key information about Debbie’s condition also contributed to her neglect. When the family moved from Leeds to Blackpool in 2016, vital information about her care needs was left out, leaving agencies in the dark of the help she required.
When the family moved, Clarke was asked by Debbie's social worker whether she would like her to make a referral to Blackpool on their behalf but Clarke declined the offer. As Debbie was an adult at this time, the decision should have been given to her.
The review said: "It remains unclear as to why it is recorded that Clarke's permission was being sought for a referral to be made. The referral was for Debbie who was an adult, thus it was her permission that was required.
"In the absence of a referral to Blackpool being made by Leeds, no information regarding Debbie's care and support needs was transferred. And most importantly, no information was shared evidencing Clarke's historic and continual inability to meet Debbie's needs."
When arriving in Blackpool, safeguarding agencies were left unaware of Debbie's skin condition or about any domestic incidents. She suffered from the severe skin infection Norwegian scabies, that had spread to such an extent that police couldn’t identify her sex when they found her body.
They were not even told that Debbie had a learning disability, meaning she was not put on the new Practice’s Learning Disability Register. If she had been registered she would have been offered annual health checks.
The review said: "Had this happened, her subsequent weight loss may have been recognised and addressed. This omission demonstrates the importance of transferring information across border."
A family member report about the neglect in 2019 was also "lost in the system". Clarke's niece, Sammy Mugridge, visited the home a month before Debbie's death.
She had found the 24-year-old lying on a filthy mattress in a dark, foul-smelling room covered in takeaway boxes and dirty nappies. She warned Clarke that Debbie would die if she was not looked after and reported her to social services.
She said: "I'll never forget the last day I saw Debbie alive. I knew she was ill and not well, but the sight of her in the room will live with me forever. The stench was unbelievable... I can only describe it as the stench of death.
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"Debbie was so skinny. Her hair had been hacked off her skin looked like raw flesh. It was like something out of a horror movie."
The review added: "These miscommunications and presumptions left Debbie without professional safeguarding support for a further six-day period before a social worker visited. By which time Clarke had tidied the house to an acceptable state and consequently, following the Social Worker visiting and not having any concerns, Debbie was again left in the care of Clarke - unsupported, invisible, and isolated."
In reality, the "lazy and selfish" mum starved her disabled daughter to death in a filthy bedroom covered in takeaway boxes and used nappies. She "bought herself handbags and shoes" while her daughter wasted away.
When Clarke, who was paid £215 a week to care for her daughter, called 999 on the evening of August 29 in 2019, it was determined that Debbie had been dead for between eight and 36 hours. When she was found she weighed just 3st 10lbs.
Clarke, from Blackpool, initially denied the unlawful killing of her vulnerable daughter but changed her plea to guilty in January just 10 days before the case was due to go to trial. She was sentenced to nine years and seven months in prison after admitting to gross negligent manslaughter at Preston Crown Court in March 2022.
John Harrison QC, prosecuting, described the terrible conditions that Debbie's decomposing body was in when emergency services found her that day. He said Debbie was "extremely emaciated with a severe rash to the scalp, the face and the soles of the feet". The clothes she was wearing were filthy and mites were found crawling on them.
Mr Harrison told the court: "A urine soiled nappy was found inside her trousers. A live maggot was found next to the body. As her clothing was cut away from her body, bits of skin came away with it as it had adhered to her body.
"Mites were found crawling all over her back. The trousers were covered in liquid faeces. Debbie's hair was falling out due to the scabies rash. Her face was covered with the rash.
"Debbie's ribs were visible through the skin. All of her limbs were wasted and the rash was widespread on them. Her buttocks were completely covered in faeces which extended down to the thighs.
"As the body was examined, large areas of skin fell away from the body. More than 30 per cent of her skin was covered in the rash, which was more severe in some parts of the body than others."
Blackpool Safeguarding Adult Boards and Blackpool Council have been contacted for comment.
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