By Aisha M Abubakar, Rowland G Seymour, Alison Gardner, Imogen Lambert, Rachel Fyson, Nicola Wright

Background

Exploitation poses a significant public health concern. This paper highlights ‘jigsaw pieces’ of statistical evidence, indicating cognitive impairment as a pre- or co-existing factor in exploitation.

Methods

We reviewed English Safeguarding Adults Collection (SAC) data and Safeguarding Adults Reviews (SARs) from 2017 to 22. Data relevant to exploitation and cognitive impairment were analysed using summary statistics and ‘analysis of variance’.

Results

Despite estimates suggesting cognitive impairments may be prevalent among people experiencing exploitation in England, national datasets miss opportunities to illuminate this issue. Although SAC data include statistics on support needs and various forms of abuse and exploitation, they lack intersectional data. Significant regional variations in recorded safeguarding investigations and potential conflation between abuse and exploitation also suggest data inconsistencies. Increased safeguarding investigations for people who were not previously in contact with services indicate that adults may be ‘slipping through the net’. SARs, although representing serious cases, provide stronger evidence linking cognitive impairment with risks of exploitation.

Conclusions

This study identifies opportunities to collect detailed information on cognitive impairment and exploitation. The extremely limited quantitative evidence-base could be enhanced using existing data channels to build a more robust picture, as well as improve prevention, identification and response efforts for ‘at-risk’ adults.

Journal of Public Health, Volume 46, Issue 4, December 2024, Pages 498–505,

By Aisha Abubakar, Rowland Seymour, Alison Gardner, Nicola Wright, Rachel Fyson, Imogen Lambert, and Rachael Clawsona

People with an illness, disability or other health conditions are more likely to experience various forms of exploitation in comparison to other groups, particularly if their health condition necessitates assistance with daily functioning such as personal care, financial management, or socialising. For the purpose of this study, we consider a wide range of cognitive impairments and differences that affect processing, understanding, and memory, and therefore may cause additional challenges in everyday life. People with ‘hidden’ disabilities such as mental health conditions, cognitive decline, intellectual disabilities, autism, and ADHD are more vulnerable to exploitation than people with other types of disability. For example, they may be vulnerable due to trauma from adverse experiences leading to dissociation, or addiction means they can be exploited to fulfil their needs. They may struggle to recognise when they are being exploited and may be unable to effectively communicate or report abuse. Adults with cognitive impairment living alone may be vulnerable, while those having difficulty understanding financial matters may be more vulnerable to financial exploitation. The aforementioned factors not only increase vulnerability to exploitation but also amplify the severity of harm when exploitation occurs, making the relationship between cognitive impairment and exploitation a complex and multidimensional phenomenon. Hence, implementing strategies that pay attention to these factors is imperative in preventing exploitation and mitigating the severity of harm. Yet, there is a lack of public and official statistics to quantify the intersections between exploitation and disability/cognitive impairment to inform appropriate strategies for mitigation. Adults with cognitive impairments may be classed as a vulnerable group of individuals at increased risk of being exploited because of their reduced capacity to identify and report abuse or exploitation. Hence the prevalence of exploitation in this population is

not well understood, it is thought to be under-reported due to the challenges faced by these individuals in communicating their experiences . Section 42 (S42) of the Care Act 2014 requires local authorities in England to conduct investigations when they have reasonable grounds to suspect that an adult with care and support needs is experiencing, or is at risk of experiencing, abuse, neglect, or exploitation. Social workers, health professionals, the police, and other relevant stakeholders are all involved in S42 investigations, with the aim of ensuring the safety and well-being of adults with care and support needs, as well as preventing and responding to incidences of maltreatment. Hence, these enquiries are intended to garner information about the adult and their circumstances, assess the risks to their safety, and determine the best way to protect them. Estimates from the Crime Survey for England and Wales (CSEW) show that between 2014 and 2020, people with cognitive impairment aged between 16 and 59 were more likely to be victims of different forms of domestic abuse and sexual assaults than people with other forms of impairment, particularly women. However, it is not possible to extrapolate what incidents reported by individuals with lived experience constitute exploitation in the CSEW. Hence this paper is an exploratory study aimed at quantitatively understanding the intersections between cognitive impairment and exploitation. Given that there is currently very little intersecting data, quantitative statements about how people with cognitive impairment are at risk of, or are being exploited, need to be extrapolated. To extrapolate the relationship between cognitive impairment and exploitation, this

study provides a descriptive account of disability prevalence, exploitation prevalence and S42 enquiries in English LAs using data from the Family Resources Survey (FRS), the National Referral Mechanism (NRM), and the Safeguarding Adults Collection (SAC), with the aim of addressing the following important questions: • Are there trends in disability prevalence and exploitation by types of impairment, and if so, what types of cognitive impairment and exploitation are more prominent? • Are there trends in S42 enquiries, and if so, what are they? • What proportion of S42 enquiries involved people with cognitive impairment? • How frequently did exploitation appear as a factor of S42 enquiries? The remainder of the paper is structured as follows. Section 2 explains what data is currently available to quantify the relationship between cognitive impairment and exploitation. The results and discussion in Section 3 then provides a contextual and descriptive account of the prevalence of disability and exploitation in England, including findings from the analysis of S42 enquiries. The final section offers concluding remarks, limitations, and emerging recommendations.

Working Paper 2023 50p.

By Alison Gardner, Aisha Abubakar, Imogen Lambert, David Charnock, Rachael Clawson, Rachel Fyson, Nicola Wright , Rowland Seymour

In recent years there has been increasing attention to ‘modern slavery’, human trafficking and wider forms of exploitation both in the UK and internationally. There has also been growing awareness that people can be placed at risk of exploitation by a wide range of personal, social and economic circumstances, including physical and mental health issues. News stories have highlighted examples of people with different forms of cognitive impairment experiencing control and exploitation by those seeking to profit from their labour or property, sometimes over long periods of time. However, statistics on this issue remain elusive. This project aimed to provide the first robust description of the intersection between cognitive impairment and the exploitation of adults in England. We were interested mainly in cognitive impairment as a risk factor prior-to exploitation, rather than impairment caused by experiences of exploitation. Whilst we recognise that there is a wide spread of IQ and cognitive ability across populations, we define cognitive impairment broadly to include both developmental and acquired impairments including intellectual disability, dementia, brain injury, autistic spectrum disorders, ADHD, functional mental health disorders and substance misuse. We also examined a diverse spectrum of exploitation looking at a range of situations where one person, either opportunistically or premeditatedly, unfairly manipulates another person for profit or personal gain. Research methods Our multi—method study included the following methods of data collection and analysis. ■ A wide-ranging scoping review of existing literature. ■ Analysis of statistical information, including data on exploitation and support needs within the Safeguarding Adults Collection (SAC) from NHS England Digital between 2017 and 2022, as well as wider contextual data. ■ Quantitative and qualitative analysis of evidence extracted from Safeguarding Adults Reviews (SARs) featuring exploitation during the same period (2017-2022). SARs (formerly known as serious case reviews) are initiated in cases where an adult with care and support needs has suffered serious harm or death, and abuse or exploitation is suspected. From our initial search of a national library of SARs we identified and analysed 58 narrative SARs featuring exploitation involving 71 people. ■ An open online survey of practitioners who were working in roles relevant to safeguarding people with cognitive impairment, which gained 95 responses. ■ Semi-structured interviews with 24 practitioners and 26 people who had lived experience of cognitive impairments and exploitation. ■ Qualitative comparative analysis (QCA) to inform our understanding of how factors combine to increase risks for exploitation.

Key findings 1 Previous studies suggest that cognitive impairments can increase vulnerability to exploitation Academic literature looking at cognitive impairment and exploitation is sparse, but our scoping review found 20 studies published in English that related to the topic. These covered three types of exploitation (sexual, financial and criminal) with intellectual disability and mental health the most frequently discussed types of impairments. The literature indicated that cognitive impairment was a factor increasing vulnerability to exploitation, but the limited number of studies meant that it was difficult to disentangle complexities in the relationship between cognitive impairment and exploitation without further research. 2 Existing datasets and surveys miss important opportunities to publish intersecting data on cognitive impairment and exploitation. Building on the literature review, we went on to examine the data that was available in England relating to cognitive impairment and exploitation. A review of statistical information found that existing English surveys and datasets currently describe the prevalence of disability and exploitation separately. With minor adjustments these could collate and publish intersecting data on cognitive impairment and exploitation, but at present these opportunities are being missed. Safeguarding Adults Collection (SAC) Data from NHS England includes statistics on support needs (including cognitive impairments) and various forms of abuse and exploitation, but has some limitations. In particular, it does not yet publish data showing the intersections between different types of support needs and forms of abuse. There were also significant regional variations in recorded safeguarding investigations, as well as potential for conflation between abuse and exploitation, which could create data inconsistencies. The SAC data did show increased safeguarding investigations for people who were not previously in contact with services, indicating that more adults with support needs may not be known to services until a crisis occurs. There were also a small but increasing number of reports of modern slavery. 3 Cognitive impairments are present within 96% of individuals in Safeguarding Adults Reviews that include exploitation Analysis of Safeguarding Adult Reviews (SARs) on exploitation showed clearer connection between cognitive impairment and exploitation. Approximately 96% of individuals in reviews that included exploitation between 2017 and 2022 focussed on adults who had some form of cognitive impairment. 4 People are often exploited in multiple ways, and alongside other abuses The relationship between cognitive impairment and exploitation is complex, with multiple forms of exploitation and abuse often co-existing and overlapping, alongside diverse risk factors. Both data from SARs and our survey suggests that financial exploitation and ‘mate crime’ (being exploited by someone posing as a friend) were the most commonly-experienced forms of exploitation. However, these more frequently observed forms often co-occur alongside others, such as sexual, labour or criminal exploitation. People with experience of living with cognitive impairment also identified ‘everyday exploitation’ as part of their regular experience, including issues like being targeted for phone and online scams. 5 Risks for exploitation arise not just from cognitive conditions, but their social impacts. The presence of a coercive and controlling relationship is a key factor. Factors identified as contributing to vulnerability included substance misuse, intellectual disabilities, mental health and dementia or cognitive decline, though in many cases there were multiple diagnoses. Complex and developmental trauma in earlier life was frequently evident. A lack of diagnosis was also a frequent challenge for practitioners seeking to support individuals at risk of exploitation. Beyond clinical factors, a range of social drivers impacted on vulnerability to exploitation, including limited or absent family support, harmful social networks, trauma and isolation. People with lived experience also described the impact of discrimination and hate-crime, and social precarity, sometimes driven through factors such as irregular immigration status or unemployment. Factors such as a history of abuse and/ or other adverse experiences such as bullying could also be present. Coercive and controlling relationships were also a significant factor predicting exploitation alongside the existence of social networks used to target a potential victim.

Nottingham, UK: University of Nottingham, Rights Lab, 2024. 58p.

By Aisha Abubakar, Rowland Seymour, Alison Gardner, Nicola Wright, Rachel Fyson, Imogen Lambert, and Rachael Clawsona

People with an illness, disability or other health conditions are more likely to experience various forms of exploitation in comparison to other groups, particularly if their health condition necessitates assistance with daily functioning such as personal care, financial management, or socialising. For the purpose of this study, we consider a wide range of cognitive impairments and differences that affect processing, understanding, and memory, and therefore may cause additional challenges in everyday life. People with ‘hidden’ disabilities such as mental health conditions, cognitive decline, intellectual disabilities, autism, and ADHD are more vulnerable to exploitation than people with other types of disability. For example, they may be vulnerable due to trauma from adverse experiences leading to dissociation, or addiction means they can be exploited to fulfil their needs. They may struggle to recognise when they are being exploited and may be unable to effectively communicate or report abuse. Adults with cognitive impairment living alone may be vulnerable, while those having difficulty understanding financial matters may be more vulnerable to financial exploitation. The aforementioned factors not only increase vulnerability to exploitation but also amplify the severity of harm when exploitation occurs, making the relationship between cognitive impairment and exploitation a complex and multidimensional phenomenon. Hence, implementing strategies that pay attention to these factors is imperative in preventing exploitation and mitigating the severity of harm. Yet, there is a lack of public and official statistics to quantify the intersections between exploitation and disability/cognitive impairment to inform appropriate strategies for mitigation. Adults with cognitive impairments may be classed as a vulnerable group of individuals at increased risk of being exploited because of their reduced capacity to identify and report abuse or exploitation. Hence the prevalence of exploitation in this population is

not well understood, it is thought to be under-reported due to the challenges faced by these individuals in communicating their experiences . Section 42 (S42) of the Care Act 2014 requires local authorities in England to conduct investigations when they have reasonable grounds to suspect that an adult with care and support needs is experiencing, or is at risk of experiencing, abuse, neglect, or exploitation. Social workers, health professionals, the police, and other relevant stakeholders are all involved in S42 investigations, with the aim of ensuring the safety and well-being of adults with care and support needs, as well as preventing and responding to incidences of maltreatment. Hence, these enquiries are intended to garner information about the adult and their circumstances, assess the risks to their safety, and determine the best way to protect them. Estimates from the Crime Survey for England and Wales (CSEW) show that between 2014 and 2020, people with cognitive impairment aged between 16 and 59 were more likely to be victims of different forms of domestic abuse and sexual assaults than people with other forms of impairment, particularly women. However, it is not possible to extrapolate what incidents reported by individuals with lived experience constitute exploitation in the CSEW. Hence this paper is an exploratory study aimed at quantitatively understanding the intersections between cognitive impairment and exploitation. Given that there is currently very little intersecting data, quantitative statements about how people with cognitive impairment are at risk of, or are being exploited, need to be extrapolated. To extrapolate the relationship between cognitive impairment and exploitation, this

study provides a descriptive account of disability prevalence, exploitation prevalence and S42 enquiries in English LAs using data from the Family Resources Survey (FRS), the National Referral Mechanism (NRM), and the Safeguarding Adults Collection (SAC), with the aim of addressing the following important questions: • Are there trends in disability prevalence and exploitation by types of impairment, and if so, what types of cognitive impairment and exploitation are more prominent? • Are there trends in S42 enquiries, and if so, what are they? • What proportion of S42 enquiries involved people with cognitive impairment? • How frequently did exploitation appear as a factor of S42 enquiries? The remainder of the paper is structured as follows. Section 2 explains what data is currently available to quantify the relationship between cognitive impairment and exploitation. The results and discussion in Section 3 then provides a contextual and descriptive account of the prevalence of disability and exploitation in England, including findings from the analysis of S42 enquiries. The final section offers concluding remarks, limitations, and emerging recommendations.

Working Paper 2023 50p.

By Dinesh Wadiwel, Claire Spivakovsky, Linda Steele

This report understands a complaint mechanism as a procedure within an organisation, institution or governing authority which allows individuals to report negative experiences and problematic conduct and policy; seek individual rectification; and, where appropriate, trigger system change. Additionally, in this report, the term ‘complaint mechanism’ can refer to the diverse range of public bodies and agencies that are made responsible for handling complaints, which includes various commissions, ombuds, government departments and bespoke complaint or oversight agencies.

Some people with disability utilise complaint mechanisms to report violence, abuse, neglect and exploitation. As shall be discussed, the use of complaint mechanisms to report such experiences creates a number of unique challenges, including whether existing complaint mechanisms are fit for purpose, whether complaint mechanisms are able to guarantee equality before the law and equal rights to justice for people with disability, how complaint mechanisms relate to other reporting pathways, in particular police and courts, and whether complaint mechanisms are able to protect individuals from violence and create system change to prevent violence. Raising these concerns does not mean that complaint mechanisms may not be appropriate or desired pathways for people with disability who want to report and seek justice for violence, abuse, neglect and exploitation. Indeed, a complaint mechanism may be able to offer forms of just process and justice in outcome that are not available through police and courts. However, much care is required in the design of complaint mechanisms as reporting pathways for violence, abuse, neglect and exploitation to ensure that they are effective in terms of process and outcome, including in achieving a broader goal of violence prevention.

This report provides guidance to the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (the Disability Royal Commission) on the design of accessible and inclusive complaint mechanisms which function as a reporting pathway for violence, abuse, neglect and exploitation. Our report puts forward an ideal approach to creating accessible and inclusive responses to complaints of violence, abuse, neglect and exploitation of people with disability. The report utilises contemporary understandings of human rights, violence prevention, procedural justice and justice in outcome to identify the principles that should inform the design of complaint mechanisms to optimise their function as reporting pathways for violence, abuse, neglect and exploitation. The report centres lived experiences of people with disability, providing extensive accounts of people navigating complaint mechanisms in relation to violence, abuse, neglect and exploitation. The report further provides a mapping of the Australian complaint mechanism landscape, through a survey of website information, and where appropriate, policy or legislation, identifying some common features and limitations of existing complaint mechanism approaches, particularly in relation to the reporting of violence, abuse, neglect and exploitation.

Our conclusions in brief (explored in detail in Chapter 8) can be summarised as follows:

a) The Structural Drivers of Violence and Complaint Mechanisms. Much of the violence, abuse, neglect and exploitation experienced by people with disability is driven by structural factors, including as a result of segregation and institutionalisation. For a range of reasons, complaint mechanisms, even when designed in accordance with ‘best practice,’ can be poorly equipped to deliver either individual rectification or the large-scale transformational change required to address and prevent violence, abuse, neglect and exploitation.

b) Complaint Mechanisms, Equality before the Law, and Legally Authorised Violence. Many complaint mechanisms are not necessarily equipped to provide justice in relation to violence, abuse, neglect and exploitation. This is because many complaint mechanisms are non-independent and combine regulatory oversight with complaint resolution processes. They are thus potentially established with a policy goal to regulate services and maintain codes of conduct, and not necessarily designed to respond to violence, abuse, neglect and exploitation from a victim-centred and justice-focused perspective. Further, if there is a social or institutional expectation that some people with disability should use complaint mechanisms, rather than police or courts, to report violence, abuse, neglect and / or exploitation, then this potentially undermines equality before the law since this means some people with disability do not have access to the forms of justice that are available to the rest of the community. This problem is further complicated by the existence of legally authorised forms of violence, such as restrictive practices. However, despite these concerns, it is acknowledged that many people with disability utilise complaint mechanisms to report violence, abuse, neglect and exploitation, and that in some cases these pathways may be preferred over the criminal justice system due to the different forms of just process and justice in outcome that they may offer.

c) Improving Process and Outcome. Based upon this report’s survey of website information, and where appropriate, policy or legislation, there are many improvements that can be made to many existing complaint mechanisms at the level of stated process and outcome to enhance their ability to respond to violence, abuse, neglect and exploitation. Improvements can be made through access to and consistency of information; dedicated reporting pathways for violence, abuse, neglect and exploitation; application of accessibility standards and the availability of supported decision making; increased clarity on how complaint mechanisms interact with and complement police and courts; and increased clarity on outcomes available as a result of a complaint, including for system transformation.

d) An Independent Complaint Mechanism for Violence, Abuse, Neglect and Exploitation. While improvements to existing mechanisms are possible, there remains a need for an independent complaint mechanism to respond to violence, abuse, neglect and exploitation, with strong perceived independence, neutrality, transparency, trustworthiness, effectiveness and capacity to support and recognise the voice of complainants. At present, this independent, dedicated, pathway for reporting violence, abuse, neglect and exploitation experienced by people with disability does not appear available within the existing terrain of relevant Australian complaint mechanisms.

e) A National Redress Scheme. Much violence, abuse, neglect and exploitation is historical in nature, including violence, abuse, neglect and exploitation that is supported by legally and socially authorised forms of segregation, institutionalisation and society wide discrimination. There is a pressing need for governments and society to acknowledge the role of historical injustices committed against people with disability in creating the conditions for current mass scale violence. In this context, a National Redress Scheme would serve an important role as both a form of transitional and transformative justice, and as an additional pathway for reporting violence, abuse, neglect and exploitation that is historical in nature.

f) Improved Processes for Police and Courts. While out of scope for this report, improvements in responses of police and courts to violence, abuse, neglect and exploitation experienced by people with disability would work in a complementary way with improvements to complaint mechanism pathways, and ensure equality before the law and equal rights to justice for people with disability.

Australia: Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, 2022. 534p.