It would be tidier if the failures of adult safeguarding in England fell neatly into one category. They do not. The same statutory regime — the same training modules, the same six principles, the same threshold criteria, the same risk-assessment instruments — produces, with depressing regularity, two opposite kinds of error: vulnerable adults who are visibly suffering and whom the system fails to protect, and competent or recovering adults whose families or homes the system disrupts in the name of protection. These two failure modes are usually discussed by different constituencies. Each constituency knows it is right and tends to suspect the other of either complacency or hysteria. They are both right, and the analytical truth is more uncomfortable than either side prefers: a regime that has lost its capacity for proportionate judgement will produce both errors simultaneously, from the same staff, in the same offices, on the same day. Neither error is the system's pathology. Both errors are its output.
What follows is two cases, each documented in the public record. The first is one of the most consequential adult safeguarding failures preceding the Care Act reforms. The second is one of the most consequential Court of Protection rulings of the immediate post-Care-Act period. Read them as exhibits of the same diagnosis.
Case A — Under-reach. Steven Hoskin, St Austell, 6 July 2006
Steven Hoskin was thirty-nine. He had a learning disability, a quiet manner, and what those who knew him described as a marked desire to be liked. He lived alone in a bedsit in St Austell, Cornwall, having moved into supported accommodation in April 2005 with a package of two hours of help each week from adult social care. In August 2005 he chose to cancel that help. In September 2005, the council closed his case.
The Serious Case Review later found that his decision to disengage "was not investigated or explored." This is a sentence whose drabness in the official prose disguises its weight. A man with a learning disability, living alone, terminating his only formal contact with social services, was not asked why. No one visited to check. No follow-up was attempted. No risk assessment was redone. The case was closed.
Over the following ten months, a small group — Darren Stewart, his girlfriend Sarah Bullock, and Martin Pollard — befriended Steven, moved into his bedsit, took his bank card, took his benefits, and began a sustained regime of physical and psychological torture. He was beaten. He was forced to wear a dog collar and led around the flat on a leash. He was burned with cigarettes. He was, by the end, terrified, malnourished and broken.
In his last months, Steven had more than forty agency contacts that presented opportunities for intervention.[1] The police were called repeatedly to disturbances at his flat. He attended A&E with injuries. He spoke to his GP. He approached housing. He approached adult social services. On at least one occasion he was visited by a community psychiatric nurse. Each of these contacts was treated as a discrete incident by the agency receiving it. None of the agencies talked to each other. No one constructed a longitudinal picture. No one asked whether the repeating pattern — frightened man, multiple visits, injuries, financial irregularities, unknown adults in the flat — added up to anything.
On 6 July 2006, Stewart, Bullock and Pollard forced Steven to swallow seventy paracetamol tablets, then marched him from his bedsit to the railway viaduct at St Austell. They made him climb the railings. Bullock kicked him in the face. He fell more than thirty metres.
Cornwall Adult Protection Committee, The Murder of Steven Hoskin: A Serious Case Review, Executive Summary (December 2007)
The Serious Case Review identified more than forty agency contacts that, in retrospect, presented opportunities for intervention. It made seventeen recommendations, focused on information sharing between agencies, recognition of vulnerable adults at increased risk, multi-agency conferencing, and the development of police and ambulance systems to flag repeat calls from the same individuals. None of the missed opportunities was, in isolation, a clear failure. Each professional who saw Steven had made a defensible local judgement about what they were seeing. The failure was systemic: the regime's inability to aggregate, to see a pattern, to ask the curious question. The pattern was visible only to someone looking at all the contacts together, and no one was looking at all the contacts together because the system was not structured to.
This is the under-reach failure as it presents in its purest form. No one decided not to protect Steven Hoskin. Every individual professional discharged their immediate duty as they understood it. The harm occurred in the gap between the immediate duties — in the space where curiosity, escalation, and the imaginative reconstruction of a vulnerable person's life would have to happen, and where, structurally, no one was responsible for them happening.
Case B — Over-reach. Essex County Council v RF [2015] EWCOP 1
P was ninety-one. A retired civil servant, a Second World War veteran, the sole occupant for fifty years of a house he had shared with his sister until her death in 1998. He lived with a companion cat. He had a form of dementia. The court found he lacked capacity, on assessment, to make decisions about his residence and care arrangements, though he retained capacity in other respects. He was described in the judgment as a generous man, ready to help others financially if he believed they needed it, and a regular donor to charity.
One of the things he did, in his late eighties, was sign cheques for people he believed needed help. Concerns arose that some of those people might be exploiting him. The concerns were not foolish. There is a substantial body of evidence that older people with cognitive impairment are at heightened risk of financial exploitation, and the local authority's duty to consider safeguarding in such circumstances is clear.
The court found that less restrictive alternatives — including the appointment of a deputy to manage P's property and affairs — should have been pursued before removing P from his home. The independent best interests assessor concluded that "the least restrictive options were never tested" and that P "was never given the opportunity and support to remain in his own home this being the least restrictive option."[3] This is the test under section 1(6) of the Mental Capacity Act 2005, the least-restrictive-option principle that governs all best-interests decisions for people who lack capacity.
What Essex County Council did instead was remove P from his home on 2 May 2013 and place him in a locked dementia unit. The procedural history of the period that followed is complex — involving family members, several review points, and shifting council positions — but the central finding of the judgment was that the deprivation of P's liberty was unlawful from the outset, because the council had not applied for any Deprivation of Liberty Safeguards authorisation at the point of removal. An urgent authorisation was not put in place until 27 June 2013, and a standard authorisation not until 4 July 2013 — two months after the removal. District Judge Mort found that P had been unlawfully deprived of his liberty for a minimum of thirteen months and arguably seventeen months.[2]
District Judge Mort, Essex CC v RF [2015] EWCOP 1
The Court of Protection found that the deprivation of P's liberty was unlawful from the outset. There had been a substantive breach of his Article 5 rights (the right to liberty) and his Article 8 rights (the right to respect for private and family life and the home). Damages were ordered, at between £3,500 and £4,600 per month. P was eventually permitted to return home with a 24-hour care package — by which time the final orders had to navigate that some family members had supported the council's position and were resisting his return.
District Judge Mort's finding — that "in my judgment the conduct of ECC has been reprehensible"[2] — has become one of the more cited statements of Court of Protection censure in subsequent commentary. Rosalind English, writing on the UK Human Rights Blog the week after the judgment, characterised the court's reasoning as "punishing the victim for the acts of the perpetrators."[3] Whether the exact phrase appears in the judgment itself or only in English's summary is a matter that subsequent practitioners and writers have not always been precise about; the analytical point — that the safeguarding intervention chosen by the council did nothing to address the actual risk (financial exploitation by third parties), and instead removed the person from his life — is sound regardless of whose words frame it. The intervention was the harm.
This is the over-reach failure in its purest form. No social worker involved decided to harm a 91-year-old man. Every professional involved understood themselves to be discharging a safeguarding duty. The harm was produced by the system's substitution of categorical responses for proportionate ones — the inability to ask whether the chosen intervention actually addressed the identified risk, and whether the cost of the intervention to the person was acceptable in light of the alternative.
Synthesis. Why one system produces both failures
Read separately, the two cases belong to different conversations. Steven Hoskin's case is cited in safeguarding training as the case that established why information must be shared between agencies and why disengagement from services must be investigated. Essex CC v RF is cited in Court of Protection practice as the case that established why removal of an adult from their home is rarely a proportionate response to financial concerns. The two literatures barely overlap. The first is read by social workers; the second by Court of Protection lawyers.
Read together, they show that the same regime — or, more precisely, the same institutional culture continuing across a major statutory reform — produced both kinds of error. Cases including Steven Hoskin's helped shape the reform climate that culminated in the Care Act 2014, alongside Winterbourne View, the Law Commission's Adult Social Care report, the No Secrets review, and a long sequence of other Serious Case Reviews.[4] The Care Act introduced the statutory section 42 safeguarding duty, the Safeguarding Adults Board, and the Safeguarding Adults Review. Essex CC v RF, decided in January 2015, was one of the first major Court of Protection judgments under the Care Act regime to find a council had wrongly deprived a vulnerable adult of liberty by reflex of the safeguarding framework. The under-reach reform and the over-reach failure occupy the same legislative moment.
This is the structural point. A safeguarding regime that responds to under-reach failures by lowering thresholds, increasing escalation, expanding reporting culture, and emphasising professional curiosity can also, on the available evidence, increase its over-reach errors. The two failure modes are not opposites; they are the same failure pattern with the dial set at different points. A regime that cannot reliably distinguish signal from noise will, by turns, miss real harms when the surface is quiet, and inflict significant harm when the surface looks suspicious — with the relationship between the surface and the underlying reality systematically distorted rather than reliably calibrated. The structural mechanisms that produce this pattern — proceduralisation replacing discretionary judgement, fragmentation of responsibility, defensive practice under uncertainty, threshold-based decision frameworks, audit/accountability asymmetry, and the inability to contextualise individual incidents longitudinally — are the subject of the diagnostic essay that accompanies this case study.[5]
Both Steven Hoskin and P were failed because no one was in a position to make the proportionate judgement that each case required. In Steven's case, no one looked at the pattern. In P's case, no one asked whether the chosen response addressed the identified risk. In both, the system's substitution of categorical compliance for judgement — what Mats Alvesson and André Spicer call functional stupidity, by which they mean organisational environments that reward procedural compliance while discouraging reflective judgement about whether actions actually make sense[6] — was the operative mechanism.
Both cases also share another feature: their findings were absorbed locally and partially. The Hoskin Serious Case Review produced seventeen recommendations for Cornwall; the recommendations have since been substantially implemented in Cornwall, and the lessons have been disseminated nationally through Safeguarding Adults Board networks and academic literature. Essex CC v RF produced a Court of Protection judgment binding on Essex; Essex's practice has since improved. Neither produced sector-wide structural change of the kind that would have prevented analogous cases elsewhere. The Hoskin lessons have not stopped vulnerable adults dying in conditions that adequate safeguarding would have prevented; the Essex CC v RF lessons have not stopped councils removing competent or recovering adults from their homes in disproportionate responses to safeguarding concerns. The propagation of learning across the sector — the property that an AAIB-style investigation body is structurally designed to deliver — is the property that adult safeguarding in England most conspicuously lacks.
The proposed National Safeguarding Board, if it is constituted with the structural features described in the supporting essay — operational independence, statutory powers of compulsion, safe-space testimony, family-initiated investigation rights, sector-wide propagation, and system-not-individual focus — would investigate both cases as exhibits of the same regime.[7] Its findings on Steven Hoskin would address the recognition of vulnerable adults at heightened risk who disengage from services. Its findings on P would address the proportionate use of safeguarding powers in cases where the identified risk could be addressed by less intrusive means. The two sets of findings would not be in tension; they would be different applications of the same diagnostic framework.
This is the test of the proposed reform. If the Board addresses only one side of the failure — protection against under-reach without correction of over-reach, or vice versa — it will fail in the same way the current regime fails, and for the same reason. A system that cannot tell signal from noise will not be improved by being made more vigilant or more cautious. It will be improved by being given the apparatus to learn from its specific failures, including the failures that are uncomfortable to its own internal constituency. Steven Hoskin and P are both that apparatus's necessary work.
Sources
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[S] Cornwall Adult Protection Committee (December 2007). The Murder of Steven Hoskin: A Serious Case Review, lead reviewer Margaret Flynn. PDF copy: https://arcengland.org.uk/wp-content/uploads/2025/02/SH-SCR.pdf . National network archived copy: https://nationalnetwork.org.uk/Historically%20Important%20SARs/2007-December-Serious-Case-Review-regarding-Steven-Hoskin-Cornwall.pdf . Subsequent academic analysis: Flynn, M. (2010), 'We will remember Steven: Cornwall after The Murder of Steven Hoskin: A serious case review', Journal of Adult Protection 12(2): 6–18: https://www.emerald.com/insight/content/doi/10.5042/jap.2010.0291/full/html . Community Care five-year retrospective: https://www.communitycare.co.uk/2011/06/29/five-years-on-from-steven-hoskin-has-safeguarding-improved/
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[S] Essex County Council v RF and Others (Deprivation of Liberty and Damages) [2015] EWCOP 1, judgment of District Judge Mort, January 2015. Mental Health Law Online case page (with judgment extracts including the "the conduct of ECC has been reprehensible" passage): https://www.mentalhealthlaw.co.uk/Essex_County_Council_v_RF_(2015)_EWCOP_1,_(2015)_MHLO_2 . 39 Essex Chambers case summary: https://www.39essex.com/information-hub/case/essex-county-council-v-rf-ors . Local Government Lawyer coverage of the damages award (including the 13–17 month deprivation finding, the May 2013 removal, the June and July 2013 authorisations, and the £3,500–£4,600 per month damages tariff): https://www.localgovernmentlawyer.co.uk/litigation-and-enforcement/400-litigation-news/23621-county-council-to-pay-record-damages-for-unlawful-deprivation-of-liberty
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[J/S] English, R. (22 January 2015). 'Nonagenarian unlawfully detained in care home for nearly two years.' UK Human Rights Blog: https://ukhumanrightsblog.com/2015/01/22/nonagenarian-unlawfully-detained-in-care-home-for-nearly-two-years/ . The "punishing the victim for the acts of the perpetrators" formulation is from this commentary by Rosalind English, characterising the court's reasoning; it has been widely repeated in subsequent commentary on the case but is not, on the available text of the judgment, a verbatim quotation from District Judge Mort. The independent best interests assessor's "the least restrictive options were never tested" is cited in English's piece from the assessor's report dated 7 July 2014.
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[S] The reform climate that culminated in the Care Act 2014 was shaped by multiple sources: the Law Commission's Adult Social Care report (2011, Law Com No 326): https://www.lawcom.gov.uk/project/adult-social-care/ ; the Department of Health No Secrets guidance (2000) and its 2009 review: https://www.gov.uk/government/publications/no-secrets-guidance-on-protecting-vulnerable-adults-in-care ; the Winterbourne View Serious Case Review (2012); and a long sequence of other adult Serious Case Reviews including Hoskin (2006), Fiona Pilkington (2007), and Stephen Hoskin's near-contemporaries. The Care Act 2014 itself: https://www.legislation.gov.uk/ukpga/2014/23/contents
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[Internal cross-reference] For the full structural argument and the six-mechanism framework that explains how both under-reach and over-reach are produced by the same institutional features, see the diagnostic essay in this series, The architecture of corporate stupidity in adult safeguarding.
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[R] Alvesson, M. and Spicer, A. (2012). 'A Stupidity-Based Theory of Organizations.' Journal of Management Studies 49(7): 1194–1220: https://onlinelibrary.wiley.com/doi/10.1111/j.1467-6486.2012.01072.x . Book-length development: Alvesson, M. and Spicer, A. (2016), The Stupidity Paradox: The Power and Pitfalls of Functional Stupidity at Work, Profile Books.
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[Internal cross-reference] For the design specification of the proposed Adult Social Care Investigation Branch / National Safeguarding Board with the six AAIB-fidelity structural features, see the supporting essay Industries that learn — and the one that won't in this series.
Source: Compiled · May 2026 · For research and journalism use