A retired police officer said the case was “particularly striking” and opportunities to take action were overlooked
A mum feels her son “could still be here” if more had been done to help him after he was stabbed. Following a review into his death four years after the incident, the mum said she was left “dumbfounded” and “shocked” he had “received so little support”.
The man, referred to under the pseudonym Joe in an Oldham Safeguarding Adults Board report, was found dead in a wooded area of Oldham in September 2024. He was 27 years old when he died.
Following his death, the board commissioned a review led by David Mellor, a retired police officer which was published in April 2026. The purpose of the review is to look at whether any lessons needed to be learned.
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Mr Mellor said the case was “particularly striking” due to “the rapid disengagement by services from working with Joe” in the months before he died. He also said “abuse in the form of suspected cuckooing and financial abuse and self-neglect may have contributed to [Joe’s] death”.
Cuckooing is where vulnerable people are exploited by a criminal gang or individuals to use the property for criminal purposes such as drug-dealing, hiding weapons and other criminal activities
In response, Dr Henri Giller, the independent chair of Oldham Safeguarding Adults Board, said all partner agencies “have committed to act in response” and the board will be “closely monitoring progress to ensure that the learning from Joe’s circumstances leads to meaningful and lasting change across Oldham’s safeguarding system to reduce the risk of similar incidents occurring in the future.”
Having lived with his family until his early 20s, the review said Joe “survived a serious stabbing incident which took place when males armed with knives entered the family home in June 2020”. Joe’s mum said he “never got over it” and “was reluctant to discuss the incident because she felt that he did not wish to relive it”.
According to Joe’s aunt, Joe had been trying to protect his mum and his two younger siblings. Described by his family as a “lovely lad” who was “pleasant, caring, and helpful”, the stabbing incident left him “tortured” and “started taking drugs to blot things out”.
The mum said she “eventually stepped away from supporting her son as it became ‘pointless’ because he would spend any money she gave him on alcohol and drugs and would pawn any phone she bought him”.
Over time, she said her son’s behaviour changed and he became “such an angry person” and on one occasion, he barricaded himself in his flat. The mum said an arrest in July 2024 was the “nail in his coffin” as bail conditions isolated him from family support, adding this isolation “tipped him over the edge”.
The family criticised local services over their response to their son. The review said his aunt “was very upset to read of the difficulties Joe experienced in the last few months of his life when several agencies closed his case and she felt that opportunities to make safeguarding referrals were missed”
His mum also said she “felt angry because she felt that if Joe had received the support he needed “he could still be here”.
The review said Joe had moved out of the family home following the stabbing incident “after a series of reported familial domestic abuse incidents in which he was perceived to be the perpetrator”. When receiving support, he was described as “angry and aggressive” and his GP planned to refer him for an autism spectrum assessment and in 2023 he was imprisoned for common assault and obstructing police.
In 2024, staff at the Pennine Care NHS Foundation Trust believed Joe “may be experiencing a first episode of psychosis” but the case was later closed. Before he died, the review said Joe was de-registered by his GP and attended the Royal Oldham Hospital “in considerable distress on several occasions”.
Mr Mellow said: “There were indications that he was being financially exploited but opportunities to make safeguarding referrals were overlooked. With hindsight, the risks to Joe appeared to be escalating but this was not recognised by the various agencies with which he came into contact in the months before he died.”
An inquest will be held to look into Joe’s death. A total of 16 recommendations have been made to local service providers, the Sanctuary Trust, and the Probation Service while good practice was found in six areas.
Dr Henri Giller, the Independent Chair of Oldham Safeguarding Adults Board, said: “On behalf of Oldham Safeguarding Adults Board, I would like to extend our sincere condolences to Joe’s family and friends. We are profoundly sorry for their loss and are grateful to Joe’s mother and aunt for their valuable time and insight and the courage they showed in contributing to this review.
“This review was undertaken to identify learning that can help prevent similar tragedies in the future. The review highlights examples of committed and compassionate practice by individual professionals, but it also identifies significant shortcomings in how risk was recognised, how services responded to non engagement, and how effectively agencies coordinated their safeguarding responses.
“The review reinforces the need for more trauma informed practice, stronger professional curiosity and challenge and strengthening of responses to adults experiencing homelessness, exploitation, and self neglect.
“The Board are taking the findings of the review seriously and have accepted all its recommendations in full. Our priority is to learn from this case.”
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