Death of disabled woman failed by multiple agencies ‘must be catalyst for change’, say family

The family of a disabled woman whose body lay undiscovered in her flat for more than three years say her death must be a “catalyst for change”, after the failure of multiple organisations to support and protect her.

They say Laura Winham was left to “fend for herself” by agencies including Surrey County Council, Woking Borough Council, the Department for Work and Pensions (DWP), and Surrey and Borders Partnership NHS Foundation Trust.

The county council had been alerted to concerns about her “vulnerability” by the police, but all its adult social care team did was try to call her – before realising her phone was no longer working – and then send her a letter, before closing her case when she failed to respond.

In a statement issued on Tuesday at the end of an inquest into her death, her family – who described her as a “much-loved, much-missed daughter and sister” – said: “Laura was clearly a person potentially at risk, but she wasn’t deemed worthy of visiting.

“She was left to fend for herself. Even her own diary entries illustrate she was unable to cope.

“Had adult social care visited Laura’s home within a few days of the referral in October 2017, then Laura would be alive.”

Shortly after the end of the inquest, a local safeguarding review – commissioned by Surrey Safeguarding Adults Board – revealed widespread failings by agencies that had had contact with Laura.

It concluded that there had been “many missed opportunities” that could have helped her in the months and years before she died in her flat in Sheerwater, Woking.

Laura was born with Goldenhar Syndrome and later developed several connected health conditions, one of which led to open heart surgery when she was 18.

She was also diagnosed with persistent delusional disorder in 2009, and had two spells of detention under the Mental Health Act, in 2006 and 2010, through the Surrey and Borders trust.

But when she was discharged from mental health services in 2010, the trust provided her with no care plan, no crisis plan, and no offers of advocacy.

From 2007, she had been living in a flat on Woking’s Sheerwater estate, which was managed from 2012 by New Vision Homes on behalf of Woking council.

But in 2013, after her employment and support allowance was stopped by DWP – possibly because she had failed to attend two work capability assessments – she fell into rent and council tax arrears and was served with an eviction notice.

Her disability living allowance was also stopped, in March 2016, apparently after telling the council she would not be able to cope with the assessment process for the new personal independence payment.

DWP appears to have failed to carry out the necessary safeguarding checks, although most of the records connected with her case have now been destroyed (see separate story).

She began to receive support from Woking council, and referrals were made to her GP and the mental health trust, but she soon moved to a new GP practice, which never saw the record of her mental health referral.

By the autumn of 2017, Laura was living on her dwindling savings and obtaining food through online deliveries.

The review said she had clearly “found the outside world frightening and oppressive”, and that her family were “frequently and consistently rebuffed”, while she was “determined to exclude her family from her life”.

Although she had some money in a savings account, she felt unable to visit the high street bank in person, which would have allowed her to withdraw cash from that account.

The safeguarding review report and coroner said she had engaged for years in a one-sided email correspondence with a member of the clergy, but he failed to seek support for her and eventually contacted the police in September 2017.

As a result of his complaint, a police officer visited Laura on 7 October 2017 to ask her to stop the correspondence, which she agreed to do, but he also asked about her welfare, and she told him she was short of money and food.

He provided her with details of a local foodbank and raised concerns about her “vulnerability” and lack of access to services through an “adult at risk referral”, which was passed to Surrey County Council’s adult social care team six days later.

But after writing just one letter that offered information about local food banks and Citizens Advice, and offering further assistance if she got in touch, and trying to call her – before realising her phone was no longer working – the care team closed her case without an assessment of her needs when she failed to respond, which the coroner described as a “lost opportunity”.

Her case remained closed until the council was told of her death four years later.

Despite the council’s failures, the coroner concluded that it was not possible to conclude that this had made a “material contribution” to her death, partly because it was not possible to “speculate” on how she would have responded if the adult social care team had visited her, and because the cause of death “remains unknown”.

She also said there had been “lost opportunities” for Woking council to “flag up Laura as vulnerable”, but she again could “not find on the balance of probabilities that these lost opportunities contributed to her death”.

Evidence suggests her last food shop took place via a Tesco delivery on 4 September 2017, and she recorded on her calendar that day that she had no money left.

She crossed off the days as they passed on her calendar and the last day she marked was 1 November 2017.

Her family believe she died soon after that date, at the age of 38.

Laura’s housing benefit and council tax continued to be paid until 2021, while a gas safety certificate was issued for her flat in January 2018, although it is likely that this was not issued lawfully. Her gas supply was cut off in 2019.

Her flat and other nearby properties were due to be demolished and other neighbours gradually began to move out, and by autumn 2020 every other near neighbour had left.

But because Woking council’s housing records did not flag her “additional needs”, no attempt was made to check how she was managing during lockdown in the early months of the pandemic.

When her father became unwell the following year, her family visited her to try to let her know about his poor health, and on seeing a build-up of post behind her front door, they began checking local hospitals and contacted the council.

When her brother returned to the flat, he saw what appeared to be part of a body in the hallway and called the emergency services.

The safeguarding review said that agencies involved in her support had made changes to their practices since the events of 2017 – although not all of them as a result of her death – including the Church of England, DWP, Surrey and Borders NHS trust, and Woking council.

Surrey County Council carried out a review of its adult social care team in February 2023, which included an audit of 158 contacts received by the social care team between 2017 and 2021 “which were closed without apparent management oversight”. This review led to a “rapid improvement plan”.

The safeguarding review concluded that, as Laura “withdrew from contact with others, the extent of her challenges became less and less visible to people and agencies who might have been able to intervene.

“When her mental health needs did become visible on occasions, we can see with hindsight that services did not mobilise to respond in ways that secured help for [her]*.”

The review also found that, if the adult social care team had visited Laura, it would have had an opportunity to “form a view about her mental state and the precariousness of her existence, offer an assessment and attempt to take appropriate action”.

Among its conclusions, and despite changes made since 2017, the safeguarding review’s recommendations include action for Surrey’s adult social care department, Woking council and DWP, and for the results of the review to be used to improve national safeguarding work.

The safeguarding adults board, which commissioned the review and whose members include Surrey County Council, Woking council, Surrey and Borders NHS trust, and Surrey police, said: “We fully accept the findings of the review which examined the role of agencies before and after [Laura’s] death.

“The review found that there were many missed opportunities, which included the need for better communications across all agencies in order to support [Laura].

“We are reassured that agencies have taken steps to address much of the learning from the events of [Laura’s] life.

“We have shared the review with all relevant agencies and will hold them to account in making sure the recommendations are acted on.”

But in a statement delivered by their solicitor, Iftikhar Manzoor, of Hudgell Solicitors, Laura’s family said: “The circumstances of Laura’s death have been absolutely devastating for her loved ones.

“They are a caring and loving family who I have come to know well over the past few years.

“Laura was a much-loved, much-missed daughter and sister.

“Her family did everything in their power to support her as she battled her mental health struggles until it became apparent she may harm herself unless they backed away.

“They believed Laura would be in the best possible hands when handing her into the care of professionals – people with much more knowledge and understanding of supporting those with serious mental health issues.

“Sadly, in this instance, that was not the case.”

They added: “The safeguarding review made it clear that Laura was never failed by her family.

“They sought professional help, but input was lost from people who truly loved her.

“Laura and her family need a system that cared enough about a vulnerable person.

“Laura’s death must act as a catalyst for change.”

*The review did not use her real name

A note from the editor:

Please consider making a voluntary financial contribution to support the work of DNS and allow it to continue producing independent, carefully-researched news stories that focus on the lives and rights of disabled people and their user-led organisations.

Please do not contribute if you cannot afford to do so, and please note that DNS is not a charity. It is run and owned by disabled journalist John Pring and has been from its launch in April 2009.

Thank you for anything you can do to support the work of DNS…