The discovery of an elderly woman pushing her heavily decomposed daughter around Walthamstow town centre in a wheelchair has sparked a promise to update local safeguarding processes.
A panel of police, council officers and NHS staff was told to reassess how it handled cases after an independent review of the tragedy.
In February, Newsquest exclusively reported on an inquest into the death of Tracey Turnell, believed to have lain dead for 14 months in the Leyton flat she shared with her mother Joan.
Graeme Irvine, senior coroner for east London, ordered Waltham Forest Council to consider disciplinary action against social workers over “significant missed opportunities” to intervene.
The inquest heard evidence the mother and daughter had lived in apparent squalor for quite some time before police intercepted Joan wheeling Tracey’s skeletal remains around the 17&Central shopping centre.
Joan had been regularly observed with faeces on her clothes and shoes, which she trailed through Whitehouse Mews, alarming the building’s caretaker, who “doggedly” raised concerns.
Neighbours also complained persistently about bad smells and fly infestations emanating from the flat.
But the council failed to properly act on a string of referrals – including one before Joan later claimed Tracey had died – simply closing them down without any proactive response.
Our reporting on the inquest triggered international media coverage and a promise by Waltham Forest Council to improve.
The BBC Local Democracy Reporting Service has now reported the outcome of a separate independent review.
Although the new report anonymised Tracey and Joan, the circumstances were so unique that the case was immediately identifiable.
It found that in January 2014, a council officer identified safeguarding concerns over Joan and Tracey, but they were not investigated “rigorously” enough.
Waltham Forest’s Safeguarding Adults Board (SAB) – made up of council officers, Metropolitan Police and staff from NHS North East London – was ordered to “urgently” investigate issues including “quality of communications at the point of referral” and closing cases “only following rigorous assessment of the facts”.
It was also instructed to update and clarify its referral and escalation processes.
But the independent review acknowledged the case was “bizarre and extremely rare”.
The pair weren’t registered with GPs and had no government documents or internet access.
Tracey didn’t own a phone and police never found a single photograph of her. She had to be identified by DNA.
The inquest heard that in 2013/4, the council encountered Joan and Tracey after they were evicted.
Concerns were noted over the way Joan seemed to speak on behalf of her “demonstrably vulnerable” daughter, who was wheelchair-bound with deformed arms and a curvature of the spin.
In hindsight, testified strategic safeguarding lead John Binding, staff should have investigated whether the relationship was “perhaps coercive in nature”.
“We didn’t do that and that was an absolute missed opportunity,” he said. “I don’t think we remotely refute that.”
They began coming to the attention of the authorities again in summer 2022, when a gas contractor raised concerns with Joan’s housing association about the state of her home.
The housing association, whose staff couldn’t enter the flat without consent, made a referral to the council – who the coroner said had done “effectively nothing”.
Further referrals in February and October 2023 also resulted in no action.
In November 2023, when the housing association tried to quiz 77-year-old Joan, she dressed Tracey’s skeletal remains in a red coat and took them out in an apparent attempt to make it look like she was alive.
When intercepted by police, she confessed Tracey had died around September 2022 but said she hadn’t wanted to let her daughter go. She was sectioned under the Mental Health Act.
Tracey’s body was so badly decomposed that no date or cause of death could be ascertained.
The independent review said: “While this case is bizarre and extremely rare and hopefully will not happen again, it shows the need to provide support to individuals in these situations.”
The SAB was told to consider its responses to “bizarre, shocking and urgent circumstances” and “what kind of leadership is required at moments such as these”.
The SAB said it “accepts the reviewer’s findings and agrees the changes needed to further improve practice".
It said it carried out several reviews through November and December and expects to “provide assurances” over its new approaches in June.
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