Adrian Munday was murdered and set fire to at his Newton Abbot home
51 year old Adrian Munday had long term mental health problems, including schizophrenia. He was also a user of legal highs.
He moved between residential and independent living throughout his life, but eventually moved into a cottage in Newton Abbot in 2015 which friends say was "perfect and Adrian loved".
But later that year, in September 2015, Adrian met Stuart Hodgkin on a train and they became friends, with Hodgkin moving into Adrian's cottage that day. His family say Adrian slept on the floor while Hodgkin slept in his bed.
Adrian was found dead at his home on 6th October 2015. He had significant injuries all over his body and his death was attributed to head and brain injuries. He'd also been set on fire.
Stuart Hodgkin was charged with murder and sentenced to life. He has since died in prison of cancer.
Now a review has found Adrian wasn't given the support he needed. And Stuart Hodgkin - an existing offender who was on probabtion - was not properly managed.
The Devon Safeguarding Adult Board concludes that "perhaps his death could have been avoided." The report says:
'The focus on Adrian's use of drugs had the effect of obscuring his other essential vulnerabilities and resulted in no contingency plans being made with Adrian on how to get support if exploited once living independently. There was failure to assess Adrian's needs once he was living independently, and there was no risk management plan produced that reflected Adrian's true situation."
It also concludes there were 'failures' in the way Stuart Hodgkin was managed as a known offender. The report says:
'Information to inform accurate risk assessment regarding SH's offending behaviour was not routinely sought or shared. SH's frequent changes of location would make a detailed assessment necessary in order to reach a coherent understanding of the pattern of offending behaviours he demonstrated, in particular his interest in identifying vulnerable men and women and exploiting any relationship with them for personal gain. And that in 2015, assessments carried out by NPS in Devon missed vital information.'
The report says since 2015, all of the agencies have seen changes to their safeguarding and risk assessment procedures.
Devon and Cornwall Police have introduced a Vulnerable Individual Screening Tool (VIST) that gives frontline officers a way to identify vulnerability, assess the needs of an individual and determine the appropriate response. The Police's Central Safeguarding Team receive the VISTs, review them and share the information as necessary with other agencies.
A new Director of Nursing and Practice has been appointed by Devon Partnership NHS Trust, and the Trust has invested in a more robust safeguarding service to support their clinicians.
The report notes that the DPT's safeguarding adults policies have been updated, and that it now provides compulsory adult safeguarding training for all its clinicians. As a consequence, the number of safeguarding adults concerns identified by clinicians has increased significantly since 2015.
CCT, now known as Step One, has undertaken a comprehensive review of its operational policies and procedures and has introduced a new system for people supported in a community setting.
And although Devon County Council did not work with Adrian Munday, it did delegate its responsibility to deliver social care to DPT. The Council has reviewed its agreements with the Trust and now has better oversight and quality assurance of the support being commissioned.
Regarding their involvement with SH, the report says that CRC has undergone extensive changes since 2015. It has a new 'operating model' that includes 'strict procedures and processes for every element of interaction with external agencies and service users.'
Siân Walker, the independent Chair of the Devon Safeguarding Adult Board, said:
"This is a tragic story of a man who had every potential to live an independent life had his vulnerability to exploitation been fully identified and more comprehensively planned for.
"There are lessons to learn and I am pleased that the agencies acted immediately since these events to improve their services.
"My thanks to the independent author of the report for her investigations and for compiling her findings, which Devon Safeguarding Adult Board today publish and accept its recommendations.
"I will ensure that we keep track of the outcome of the recommendations by working with our partners to regularly review practice and improvements.
"My thoughts and sympathies are with Adrian's family, and I hope that the publication of this report helps them in some small way as they struggle with the impact of the loss of their beloved son and brother in such terrible circumstances."
Speaking to Radio Exe, Adrian's twin sister says: "The review has been useful for us as a family because it's given us answers to the questions we didn't have. We're kind of beginning to pick ourselves up, but always with that sense of loss. Particularly at Christmas, because Adrian loved Christmas. I mean at birthday times as well, for me, because it was always his birthday too."
An inquest is yet to take place.