An independent inquiry into the circumstances leading to the death of Margaret Fleming has been published today, Wednesday 18 October 2023, with a series of wide-ranging recommendations being proposed.

The inquiry, known as a Significant Case Review (SCR), was commissioned to examine the role of all the agencies that were involved with Margaret and the circumstances that led to her death.

An SCR is normally held when a person involved with health and social care services has died or suffered significant harm.

In Margaret Fleming’s case, the SCR was jointly commissioned by the Adult Protection Committee and Child Protection Committee and led by Professor Jean MacLellan OBE.

Prof MacLellan spoke to more than 100 people, including Margaret’s family and friends, during the course of the wide-ranging review and a series of recommendations have been made for all agencies involved to consider and look to implement.

Additional workings and research carried out as part of the extensive review has also been published to help with learning for professional organisations and individuals.

This has been published on a special website that was created for anyone who knew Margaret to come forward and provide information.

The recommendations of the review, entitled ‘Remember My Name’, includes some key themes:

• There have been significant changes in legislation and practice over the last 20 years, however, there is still learning from the review.
• Information sharing and communication. All agencies are required to understand how to share information timeously to ensure vulnerable people are protected.
• Checks and balances should be in place that balance people’s rights to privacy with a clear need to protect vulnerable people who need to be seen by agencies and this includes benefits agencies. Expansion of annual health checks for adults with learning disabilities should be considered.
• Transition from school to college is difficult for any young person. All colleges and universities should have robust adult protection guidance. An audit through the Further Education Safeguarding Forum should take place across Scotland.
• As a society, everyone has a responsibility to ensure that people with disabilities are seen and protected. Listening to those with lived experience is important to understand how to improve services. Each local authority should be clear on its mechanism to hear the views of people with learning disabilities and understand the local provision. This should be mapped out and made publicly available.
• Margaret should be remembered, and Inverclyde Council should consider how this happens in a way that is respectful to her family.

Alex Davidson, chair of the Adult Protection Committee, said: “The death of Margaret Fleming and the tragic events that led to her death shook not only the local community but the whole of Scotland.

“This wide-ranging and in-depth review provides learning for all agencies involved in Margaret’s life to ensure lessons are learned from the circumstances that led to her death and, as the title says, honours and remembers Margaret.

“It is now up to each agency to consider the findings and take those forward but what is clear to me from the review is that agencies need to talk across the fence to each other when it comes to partnership working and information sharing to ensure vulnerable people are seen in person while respecting their right to privacy.

“See something, say something. If something doesn’t seem right, it probably isn’t and there should be a multi-agency response to that. The same applies to society in general and we have a collective responsibility to look out for each other and speak up if something doesn’t seem right.

“The committees would wish to thank Professor MacLellan for her work on the report, and the many individuals and organisations who contributed to it.  

“Thanks are especially due to Margaret’s mother and to her father’s fiancée.”

Prof MacLellan said: “For many of us, what we know of Margaret’s life is what was covered in the televised trial and subsequent media coverage of her murder which, by its nature, highlighted the trauma of her experience. This review had a different emphasis. It was to understand what we could about who she was and what the agencies that had been involved with her and her family had offered.

“Inverclyde recognised the challenges of doing this well given that so many years had passed since Margaret died. So it was agreed that an Appreciative Inquiry approach would be adopted. This meant that staff committed to being active in finding any records relating to Margaret. The disciplines spoke freely to each other about what they found. It was openly acknowledged what could be improved and staff have set about doing so well in advance of the publication of this report. Readers can access much of this material on a dedicated website for training and learning purposes. My role has not been a top-down, external, one but as part of this dedicated team. I am grateful to them all. This approach has much to commend it.

“Like others, I would like to thank Margaret’s mother whom I have come to know well. She is a private individual who is entitled to remain so. She has co-operated wholeheartedly with the review and will be forever impacted by her daughter’s death. I would also like to thank Margaret’s father’s fiancée and her daughter for their substantial contribution to our collective understanding.

“My last comments relate to the many people with learning disabilities and carers, locally and across Scotland, who participated in the review. Their testimony appears in detail on the website too and vividly describes life in Scotland now. This aspect is Margaret’s legacy and is for the Margarets of today and the Margarets of the future.”

The final report will be sent to the Care Inspectorate, which evaluates all SCRs and reports publicly on their findings to provide the public with an independent check on the quality of the services that are provided for children, young people, and adults.

Significant Case Reviews are intended to make sure that awareness about how vulnerable people have come to harm is widely shared and to promote improvements in child and adult protection across the country.

The full report has been published on Inverclyde Council’s website.