Learning disability charity Mencap has called for improvements to adult safeguarding after the serious case review into the death of Gemma Hayter criticised care agencies.

Gemma Hayter, 27, who had learning disabilities, was found dead on a disused railway line in Rugby in Warwickshire in August 2010. She had been beaten and tortured before she died by people she considered to be her friends. In September, three people were jailed for life for her murder. The serious case review by Warwickshire Safeguarding Adults Partnership found no evidence that Gemma’s death could have been predicted or prevented. But the review added that there was “clear evidence” that Gemma was vulnerable to the risk of abuse and that she had been a victim of ‘mate crime’ on a regular basis in the past. The review concluded no single agency had a full picture of what was happening in her life and that there were a number of missed opportunities for initiating safeguarding procedures, assessments or other interventions.

David Congdon, Mencap's head of campaigns and policy, said: “[The] serious case review into the death of Gemma Hayter raises many questions about how social services and other public bodies respond to the needs of vulnerable adults in their communities. “It is clear from the review that no agency took full responsibility for Gemma’s case and this tragically contributed to her death. All of this reinforces the need for adult safeguarding to be given a strong legislative framework to help keep vulnerable people safe.”