Chances to protect highly vulnerable Michael Gilbert - whose headless body was found dismembered in Arlesey Lagoon - were missed by the authorities who failed in their duty of care towards him.
Three police investigations were flawed due to misinformation failures in communication and human error, preventing Michael from getting the vital help he needed.
On Thursday, representatives from Luton Borough Council and Bedfordshire Police explained they had learned lessons from a case which has effects so far-reaching they will shape policy on a national level.
The authorities came into contact with Michael countless times over a period of many years. But they never took any of those opportunities, leaving him to suffer a life as a tortured slave before his murder in 2009.
The case review, stated: ‘At different stages of Michael’s life, he was known as an alleged child sex offender, a care-leaver, homeless, a glue sniffer, a user of cannabis, an associate of criminals and responsible himself for crimes against the person, against property and crimes of theft, long term unemployed. Such roles powerfully affected some professional judgements about his vulnerability’.
Luton Borough Council’s chief executive, Trevor Holden, asked the media not to publish details of what happened to Michael as a child, so terrible were his experiences.
He left his family home aged 15 and went into the care system. It was here that he befriended James Watt and subsequently he became a part of his family where he became their slave.
In 2002, a member of Michael’s family called Bedfordshire Police to report that he had been cut with a knife and shot with a pellet gun.
A statement was taken and three members of the Watt family were named as the offenders. Detectives made calls to Michael but did not follow them up when they went unreturned.
In July 2007, Bedfordshire Police did not inform Cambridgeshire colleagues, who had an open missing person and abduction inquiry concerning Michael, that he had made an allegation of abduction after being questioned on suspicion of rape.
On January 28, 2008, Michael was abducted from outside a job centre in Blackburn.
On February 1, the police were informed and they attended his girlfriend’s house, where they took a contact number for Michael. An incorrect number was written down by the officer.
In the Luton Safeguarding Vulnerable Adults Board (LSAB) report it states: ‘The years 2003- 2009, were a disaster once agencies ceased to have any responsibility for Michael.’ The Independent Police Complaints Commission (IPCC) report also highlighted serious shortcomings and missed opportunities.
IPCC Commissioner Rachel Cerfontyne said: “We looked at specific allegations that the police did not investigate three incidents involving Michael and the Watt family.
“We have found that on each occasion investigations had taken place, but were flawed due to misinformation, failures in communication and human error.” The review by LSAB has made eight recommendations in a hope that lessons will be learnt and there will not be another Michael Gilbert case.