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In February 2016, the Board received the Serious Case Review of young woman with learning disabilities thought to have been the victim of domestic violence and sexual exploitation.

The collar itself caused friction to her skin resulting in the formation of a pressure ulcer.

This ulcer in turn eventually became infected and Mrs D died as a result of the septicaemia, or infection based blood poisoning which it caused.

She died eleven days after being discovered by a visiting district nurse and her admission to hospital.

Police investigations concluded the action or lack of action of any person did not meet the criminal threshold of wilful neglect or ill treatment.

The SCR found that Mrs Foster would have benefited from better multi-agency care coordination and review from August 2009.