'Missed opportunities' before nursing home rape - review

A man caught allegedly raping a woman with dementia at a nursing home had shown concerning behaviour in the days leading to the attack, a review found.

Staff walked in on the man, who had an alcohol-related brain injury, when he was on top of the woman in her room in the Liverpool home in August 2022.

A recent review by Liverpool Safeguarding Adults Board (SAB) said the man was arrested but was not prosecuted as he lacked capacity.

The review raised questions about the decision to place him in a mixed sex facility and noted his care plan has not been re-examined despite him touching a staff member inappropriately, harassing a resident and entering the victim's room on a previous occasion.

The man, referred to as Kenneth in the review, was placed in the home for assessment after a hospital stay on a 28-day basis.

However, social workers and hospital staff had shared "incomplete information" in a handover to the care home manager.

This included not informing the home that Kenneth had been under one-to-one observation at hospital due to his "challenging" behaviour.

Kenneth's family also told police that a social worker had advised them not to share everything they knew about his "violent and aggressive" past behaviour because then adult social care teams would "struggle" to find him a placement.

The review said it had been unable to confirm who made the comment but described it as "unfortunate".

A brokerage team from Mersey Care NHS Foundation Trust were tasked with finding somewhere for Kenneth to be discharged from, it said.

It raised questions about the choice of care home, which had been rated "inadequate" in some areas by a Care Quality Commission inspection team.

The report said when Kenneth arrived at the home he was placed under hourly observations overnight to check for any "patterns of behaviour that needed additional support".

However, it said: "In the days leading up to the alleged rape, there were missed opportunities to review Kenneth's risk assessments and care plan.

"The behaviours documented by staff, such as Kenneth being awake at night, knocking on other residents' bedroom doors, harassing a resident, entering Dorothy's bedroom, and inappropriate touching of a female staff member, were reported to the home managers at the time they occurred, but these incidents did not prompt an earlier review of his care plan."

The care home was praised for its immediate response to the attack, which saw both Kenneth and Dorothy (not her real name) assigned a one-to-one carer and both police and paramedics being called.

However, it criticised how Kenneth's family were informed about the incident.

It said the care home told a relative over the phone, while she was in a public place, that he had raped another resident and that he had been arrested.

The review said the conversation caused the relative a "great deal of distress" and resulted in her suffering a panic attack.

Communication with the families of both residents was described as "poor" after the incident.

Dorothy was examined at hospital, where medics noted bruising to her thigh, but was not examined at a specialist Sexual Assault Referral Centre due to high demand.

Merseyside Police concluded that Kenneth would never have capacity to be interviewed about the alleged rape and he was released, and was not permitted to return to the care home where he had attacked Dorothy.

The review said since the assault the care home had changed its practices so any inappropriate behaviour within 72 hours of admission would trigger a review of their risk assessment and care plan.

It said the home would also enquire about any "sexualised inappropriate behaviour" or police investigations before accepting a new resident.

A spokesperson for Liverpool SAB said: "We have offered the families of both individuals our sincere sympathies for what they had to experience.

"The review details several learnings for agencies which has been acted upon."

The care home operator has been contacted for comment.

Listen to the best of BBC Radio Merseyside on Sounds and follow BBC Merseyside on Facebook, X, and Instagram. You can also send story ideas via Whatsapp to 0808 100 2230.