A vulnerable elderly woman with dementia was repeatedly let down by health and social services, before she died at the hands of her son, a report has revealed.
Ellen Ash, 83, was killed by her son and carer Jeffrey Ash, who smothered her and attempted to burn her body in March 2013. He was sentenced to three years and four months in prison in September the same year after pleading guilty to wilful fire raising and culpable homicide.
The significant case review from Glasgow's Adult Protection Committee says Mrs Ash came to the attention of social services in 2011. She was suffering from Alzheimer's disease and high blood pressure, but subsequently suffered repeated hospital admissions for conditions including infections, hypothermia and an necrotic sore on her heel.
Her son insisted she did not need residential care and continued to care for her. While the report concludes there was no reason or specific evidence to suggest that Mr Ash would harm his mother, professionals failed to challenge him over her need for better care.
There were repeated communication failings, including frustrations and tensions between health and social services which got in the way of ensuring the safety of a very vulnerable elderly woman.
The report says: "continuing confusion and erroneous assumptions regarding the level of home care service was compounded by the absence of case management and reflects poor professional practice and a fundamental break down in the system to meet the risk and care needs of a vulnerable person."
Allegations of possible abuse by Mr Ash were not responded to adequately and assumptions were made that he would ask for help if he was struggling to cope. There was a "fundamental breakdown" in systems to share information between the relevant agencies.
The report says those involved should consider whether the 'inconsistent and fragmented approach' and other failings in Mrs Ash's case are unique to her case or prevalent throughout the support and protection system.
Colin Anderson, Independent Chair of the Glasgow Adult Protection Committee said: "This has been a particularly tragic and upsetting case to review.
“There was no reason for care staff to suspect that Jeffrey Ash was other than a caring and well intentioned son who did not pose any kind of threat to his mother".
However Mr Ash should have asked for more support and when he did not those involved in providing for care should have raised the level of alert, he said.
“The evidence we gathered during the review process points clearly towards the social care and health services for Mrs Ash breaking down in an unacceptable manner.
"The handling of her case involved instances of poor practice, poor communication between different teams, a lack of thorough and coordinated assessment and an assumption that Mr Ash was capable of providing his mother with a safe and appropriate level of care.
“In this case the right to support and protection and the right for an individual or a carer to determine how care and support should be managed was well out of balance."
He said he was reassured that the services criticised in his report were already acting on its findings.
"I have made absolutely clear that our committee will receive regular reports, and if necessary, take further action to ensure that the recommended improvements are properly implemented."
A spokesman for Glasgow City Council said: “We fully accept the criticisms contained within the significant case review.
“It is clear that we should have done more to support both Ellen Ash and her son and had opportunities to do so.
“As a direct result of this report we are now implementing an action plan to improve our practice in this area as a matter of urgency.
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