Case two: ‘The case of the vulnerable adult’

In March 2002, a 30-year-old woman with learning disabilities was admitted to Borders General Hospital in Scotland with multiple injuries as a result of sustained physical and sexual assaults. The abuse had been carried out at home and was perpetrated by three men, one of whom was her carer. ‘The case of the vulnerable adult’  is the term that the individual involved has asked to be used. Her identity is protected under rules giving anonymity to victims of rape.

What happened

The woman had made allegations against one of the perpetrators as a child but agencies decided her mother could protect her. When her mother died, he was allowed to become her carer, making her sleep on a carpet in the hall at his home. He began taking the woman's benefit money, deprived her of food and liquid and made her sit in the dark for long periods. Together with two friends he forced her to strip, shaved her head, sexually assaulted her and repeatedly stamped on her face and body. They also threw the woman over a fence, handcuffed her to a door and set fire to her clothing.

The police, health and social services had been aware of allegations of abuse dating back to the woman's childhood. These had been investigated and reported to the Procurator Fiscal but she was considered an unreliable witness due to her learning disability.

The response

The woman had been known to police, social work services and the health board from her early childhood. As a subsequent investigation into the case found, ‘Over many years, there were events and statements in records held by social work, health services and the police that raised serious concerns about this person's [the primary carer following the mother's death] behaviour toward this woman’.[1] In the period leading up to the ‘vulnerable adult’s’ hospital admission in 2002, the abuse had clearly escalated to extreme levels.

A police investigation into the circumstances of the ‘vulnerable adult’ was triggered when a neighbour reported his concerns. This coincided with the admission of the ‘vulnerable adult’ to Borders General Hospital. As the ‘vulnerable adult’ had experienced disbelief previously at the hands of the police,[2] it was important for the officer leading the investigation to be able to build sufficient trust with her for the investigation to make progress.

During the investigation it emerged that another person with learning disabilities was also experiencing sexual abuse and another was experiencing severe physical neglect within the same network. One had previously disclosed abuse but had been dismissed as unreliable. One had been receiving services from both the Council and Health Board and had suffered severe forms of neglect and abuse over many years. The professionals involved included: social workers, GPs, district nurses, the learning disability specialist team, general hospital services, dieticians and the police.

Scottish Government, 2004, Investigations into Scottish Borders Council and NHS Borders Services for People with Learning Disabilities: Joint Statement from the Mental Welfare Commission and the Social Work Services Inspectorate. Available from the Scotland Gov website

2 In part due to having been inaccurately assessed in the past as having only a mild learning disability; officers acting on this assessment therefore took her prevarication as deliberate evasion and a refusal to co-operate.


Numerous allegations over a period of 20 years did not result in criminal proceedings being taken until the intervention of a neighbour resulted in decisive action in 2002. The criminal case against the three men focused on the three month period leading up to the ‘vulnerable adult’s’ hospitalisation. In September 2002, the carer received a sentence of 10 years’ imprisonment and the other two men sentences of seven years.

The Offences (Aggravation by Prejudice) (Scotland) Act (2009) was not introduced until some time after this case and so the offences could not have been prosecuted as hate crime.

Review process

There have been a number of investigations and reports in relation to this case, both internal and external. The most significant was a report by the Social Work Services Inspectorate (SWSI) which was commissioned by the Minister for Education and Young People into the social work services provided to people with learning disabilities by the Scottish Borders Council, and a parallel investigation by the Mental Welfare Commission into the involvement of health services. The findings of these two investigations included:[3]

  • failure to investigate appropriately very serious allegations of abuse
  • poor assessment of need and engagement with service users
  • unco-ordinated approach to assessment, service provision and monitoring
  • lack of information-sharing and multiagency working
  • poor record keeping and poor supervision of frontline staff
  • inability and/or unwillingness to confront aggression and staff’s consequent collusion with aggressors to the detriment of victims
  • lack of senior management and leadership
  • no means to resolve disputes between agencies as to appropriate course of action.

The reports were published in 2004 and made recommendations both for the agencies in the Borders area and more widely for the adult protection system in Scotland. This resulted in a number of changes, most significantly the development of the Adult Support and Protection (Scotland) Act 2007, which introduced a rights-based framework to adult protection. A follow-up inspection [4] in the Borders area was published in 2005 and showed that real progress had been made.

Overall the inspection found:

  • that agencies were more likely to be aware of abuse of disabled people and take action to stop it
  • that people with learning disabilities knew who to contact if they were being abused
  • improvements in training, information sharing, record keeping, leadership and management.

The inquiry found a number of ways in which public authorities had improved practice in areas such as governance, information sharing and guidance, notably including:

  • Co-operation and multi-agency working which benefited from the creation of a ‘Critical Services Oversight Group’. This brings together the senior leaders of all agencies in the Borders to review progress on protecting vulnerable adults. These authorities are also part of the Edinburgh, Lothian and Borders Executive Group (ELBEG) which again involves the most senior officers and officials providing oversight of arrangements for protecting vulnerable persons. All ELBEG partners have signed up to the group’s ‘Adult Support and Protection: Ensuring rights and preventing harm’ Multi-agency Guidelines, published in January 2010.
  • The Director of Social Work working in partnership with the Scottish Government to lead a programme of work on practice governance. This has led to publication of guidance on the role of the chief social work officer and the registered social worker and a framework for practice governance. [5]

Further details of a range of sustained improvements which have been made are covered in Appendix 17.

3 Scottish Government, 2004, Investigations into Scottish Borders Council and NHSBorders Services for People with Learning Disabilities: Joint Statement from the Mental Welfare Commission and the Social Work Services Inspectorate. Available from Scotland Gov website.

Scottish Government, 2005, “No fears as long as we work together” – Follow Up Joint Inspection of Scottish Borders Council and NHS Borders: Verifying implementation of their action plan for services for people with learning disabilities. Available from Scotland Gov website.

See Scotland Gov website






Last Updated: 05 Mar 2014