Investigation shows opportunities were missed to help disabled Blackpool woman Debbie Leitch who was starved to death

Debbie Leitch was found dead in her faeces-covered bed on August 29 2019, weighing just 3st 10lbs and covered in one of the wort cases of a scabies skin infection doctors had ever seen.

It was discovered that Debbie, 24, had been slowly starved by her neglectful mum – Elaine Clarke 49, - who later pleaded guilty to her manslaughter and was sentenced to nine years and seven months in prison at Preston Crown Court in February 22.

However, a tragic failure in communication between the various departments who dealt with Debbie meant the true risk to her wellbeing was never fully realised until it was too late and she was found dead.

While Debbie had been under the watch of social workers with Blackpool Adult Services, key information about Jessica’s neglect had not been passed on to them by their counterparts in Leeds, and once in the resort, there had been further miscommunication between the resort’s social workers and Jessica’s GP.

Blackpool’s Adult Services have accepted that its staff were fooled by Debbie’s manipulative mum, who often tidied up the house and her daughter for their visits, and they failed to see she was in serious danger.

As a youngster in East Sussex, Debbie had frequently presented in school with head lice and ill fitting clothes, and after the family loved to Leeds in 2013 a day care centre she attended also noticed that poor clothing and headlice and a failure by her mum to provide any packed lunch for her were regular occurrences.

But when the family moved to Blackpool, Leeds did not pass on the sufficient details which would have helped direct Debbie’s care in her new home.

The report, commissioned by the Blackpool Adult Safeguarding Board, was aimed at ensuring lessons could be learnt so that similar mistakes could not happen again.

What they had to say

Karen Smith, Director of Adult Services, said: “Throughout this review our thoughts and condolences have been with (Debbie’s) extended family.

“We know her mother manipulated circumstances so her neglect was not apparent to ourselves and other agencies visiting their home. However, it is clear from the review that there were missed opportunities and Jessica’s voice was seldom heard.

“This tragic death has taught us a lot and changes have already been implemented.

"Our processes have been improved, along with the way we share information with other councils and local agencies.

“This learning will be shared with all practitioners to improve the care we provide to vulnerable residents.”

Richard Jones, Independent Chair of Leeds Adults Safeguarding Board said: ‘We were saddened to hear of the untimely death of this young woman who had lived for some time in Leeds

"Following the findings and recommendations of the SAR, Leeds City Council completed its own review from which the relevant learning was obtained and changes implemented at the time of the original request.

"The Safeguarding Adults Review Report was presented to the Leeds Safeguarding Adults Board last week and assurance of the changes made is being provided to the Board.”

Debbie’s father, Thomas Leitch, who lives out of the area, said after reading the report: “All of the departments involved in my daughter’s case could have done more, including Blackpool’s social services.

"The communication between them all was just not good enough and they missed so many things.

"Blackpool social services must have realised something was not right and should have made more unannounced visits and spoken to my daughter personally instead of letting her mum control the situation.

"They were just fobbed off too easily.

"Her mother was not capable of looking after her properly and that should have been obvious.”

What the report concluded

The report concluded: “(Elaine) neglected (Debbie) from birth.

"Professionals working with (Debbie) were not always aware of this as she was moved to different parts of the United Kingdom by family on three occasions in her life.

“The final move being from Leeds to Blackpool in 2016. No information regarding her care needs or circumstances was communicated from Leeds to Blackpool.

"Occasions for agency intervention in Blackpool arose due to (Debbie’s) skin condition, a domestic incident and (Elaine’s) request for support, and these occurrences created opportunities for cross-border discussion, which...were not ensued.

"Their omission contributed to the aforementioned neglect not becoming known to Blackpool to inform (Debbie’s) future risk management and support.

“This was particularly dangerous because, as (Debbie) lived with Down’s Syndrome ...and did not have capacity to make all of her decisions, professionals were allowing her mother to convey her wishes and feelings on her behalf. (Debbie) was not heard, and (Elaine) made her decisions.

“When in July 2019, a family member alerted Children’s Social Care to her neglect, Children’s Social Care made a referral to Adult Social Care.

"Unfortunately, this proved ineffective as it got lost in the system. The information provided to Adult Social Care (from the family) diverted focus to (Debbie’s) health.

"Adult Social Care considered the urgency of this to be addressed by a GP visit. The GP, made aware of some of the concerns by a family member, presumed that Adult Social Care would be addressing the safeguarding and focussed wholly on (Debbie’s) skin.

“These miscommunications and presumptions left her without professional safeguarding support for a further six-day period before a social worker visited.

“By which time her mother 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 her mother - unsupported, invisible, and isolated.

“ There is no doubt that (Debbie) was failed and unless the learning of this review is used to develop practice, the same outcome could befall other adults at risk in her situation.”