Blackpool coroner finds Debbie Leitch, 24, was starved to death and unlawfully killed by neglectful mum
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Debbie Leitch, 24, who had Down's syndrome, was found dead at her home in Garden Terrace, South Shore on August 29, 2019.
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Hide AdA three-day inquest opened on Monday and concluded yesterday, with Alan Wilson - senior coroner for Blackpool and Fylde - finding Debbie died from "the combined effects of her severely emaciated and neglected state, and debilitation caused by widespread Norwegian scabies mite infection".
The 24-year-old weighed just under four stone (25kg) at the time of her death, having previously been more than ten stone (63kg), the inquest was told.
Disgraced mum and full-time paid carer Elaine Clarke was jailed in 2022 for nine years and seven months after pleading guilty to gross negligence manslaughter. She initially denied the offence and refused to take part in the inquest process.
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In his ruling Mr Wilson stated: "Debbie had care and support needs, and a range of carers and social care professionals would attend the home regularly to provide that care.
"Unbeknown to them, the standard of care shown by Debbie's mother was at times inappropriate, and she would take steps to actively try to mask how she was treating Debbie."
He added: "At other times, she may use disguised compliance to give professionals the false impression that she was doing what she could to comply with any plans to safeguard or promote Debbie's welfare when this was not the case, such as by agreeing to medical appointments which would then be missed, often providing a seemingly plausible explanation."
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Mr Wilson said Debbie's cousin Stacey Muggridge raised concerns after visiting the family home on July 26, 2019.
Ms Muggridge had been ‘horrified’ by Debbie’s appearance, claiming she found the 24-year-old lying on a filthy mattress in a dark, foul-smelling room covered in takeaway boxes and dirty nappies.
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Hide AdIn a written statement, she said Ms Leitch had been struggling to walk and was wearing soiled pyjamas. She also noted how some of her hair appeared to have been "hacked off".
Debbie ‘failed’ by GP and social services
She arranged to visit the home with social services and her GP, but by the time the GP arrived, Clarke had "taken steps to make both Debbie and the house more presentable, and she reassured the GP that Debbie was being appropriately cared for".
Six days later, a social worker from Blackpool Council visited the home and "was similarly reassured".
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Hide AdMr Wilson said the family GP did not show enough professional curiosity on their visit, despite Debbie's severe weight loss and incontinence.
The coroner also found social workers and carers did not ask enough questions about her condition and were ‘easily influenced’ by her mum, Elaine, who had hidden the truth about her neglect.
He described the case as "particularly sad" and "tragic" due to the failings on the part of the professionals who visited Debbie's home and failed to take action before she died.
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Hide AdHowever, Mr Wilson did not issue a Prevention of Future Deaths report as he was satisfied the professional agencies who had failed Debbie have since changed their habits.
Maggots at scene of death
On August 29, ambulance crews were called to the house in response to a report a woman had gone into cardiac arrest. Paramedic John Wilkinson, from North West Ambulance Service, found Debbie in an ‘unnatural position’ on the floor of the untidy room, where he reported seeing maggots. She had been dead for a number of hours. Join our new WhatsApp Community to get the latest news and top stories from across Lancashire directly to your phone
Coroner’s verdict
Mr Wilson said: "The conditions in which she had been living were described as uninhabitable.
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Hide Ad"As a result of the way she had been neglected over the preceding four weeks, a subsequent post mortem examination revealed she died from the combined effects of her severely emaciated and neglected state, and debilitation caused by widespread Norwegian scabies mite infection, which is regarded as a treatable condition.
"Significantly, the fact that Debbie had Down's Syndrome, a learning disability, made it more likely that her mother would be able to persuade others she was providing an acceptable level of care for Debbie."
He concluded that the cause of her death was severe emaciation, neglect and scabies and ruled she was unlawfully killed.
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Karen Smith, Director of Adult Services at Blackpool Council, said: “Since the time of Deborah’s untimely death our thoughts and condolences have been with her extended family.
“We know Deborah’s mother manipulated circumstances through disguised compliance when dealing with professionals so that her neglect was not apparent to ourselves and other agencies visiting their home and that she was subsequently convicted of gross negligence manslaughter in 2022.
“However, it is clear from the work undertaken since the time of Deborah’s death in 2019 and the review that was published in 2023 that there were missed opportunities and Deborah’s voice was seldom heard.
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Hide Ad“Deborah’s tragic death has taught us a lot. Following the review, changes have been implemented and are now embedded in our social work practice.
"Our processes have been improved, along with the way we share information internally, with other councils, our partners and local agencies in order to improve the care we provide to vulnerable residents.
"We have also shared the learning more widely through the Safeguarding Board, which has also overseen the assurance that the actions identified have been taken.”