Vulnerable man left in ‘squalid’ conditions

AVULNERABLE man died after being found lying in squalid and unhygienic conditions because his care provider failed to provide appropriate support for him.

Adrian Green, 55, was found in an unresponsive state in his supported living accommodation in Paignton and then died a few days later at Torbay Hospital on November 1, 2021, an inquest heard.

The evidence revealed that while a resident at Whitley Court during the coronavirus pandemic, the previous manager of the facility and a number of staff members left the employment of Care Support Torbay and South Devon branch on October 15, 2021, in an “unplanned way, deleting records and electronic information as they went” which left the service in “chaos”.

Many visits were said to be carried out by intercom calls only which was against company policy. It was added the service was run by agency workers who had “no direction or guidance”.

The coroner’s investigation into his death returned a narrative conclusion that Mr Green died from alcoholic liver disease where opportunities to prevent his medical deterioration were not taken.

Assistant coroner Deborah Archer has sent a prevention of future deaths report to Torbay and South Devon NHS Trust to highlight her concerns surrounding his death and fears that another death could occur.

A Coroners Court hearing heard Mr Green lived at Whitley Court from November 4, 2019, to October 26, 2021. He was said to have meant to be receiving assistance via a care package with medication, support and care, meals and shopping.

Although the case was originally reported to independent health and social care regulator Care Quality

Commission (CQC), it was heard it had “declined” to prepare a report because it said it was not a case that fell under its jurisdiction because Mr Green did not receive “personal care”.

A manager from Care First was said to have disputed that at the inquest. It was heard that welfare concerns were raised about Mr Green by a neighbour who had not seen activity in his flat for a while.

An employee, unnamed in the report, was said to have told the inquest she had been asking the Devon service from London whether there were any issues with staffing or coping during the pandemic and said she was told there was not.

After the manager and some staff left Whitley Court on October 15, 2021, Mr Green was said to have not been not receiving “any sort of appropriate care or visits” from around October 1, 2021.

The report stated: “Mr Green was left lying in squalid and unhygienic conditions in an almost unresponsive state from October 23, 2021, to October 26, 2021, when [redacted] found him having arrived from London the previous day and called paramedics. Mr Green was conveyed to Torbay Hospital but passed away on November 1, 2021, with his family being told that if he had received medical attention sooner he would have had a 50% per cent chance of surviving. [Redacted] raised a safeguarding alert to the police and the trust and made a referral to the Disclosure and Barring Service.”

Stating her concerns to the trust in the prevention of future deaths report, Ms Archer said: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you.

“Despite there being a safeguarding meeting on January 22, 2022, following Mr Green’s death there appeared to be no review of whether the local authority ought to have had policies in place to ensure that independent providers were adequately carrying out their contractual duties towards vulnerable individuals, especially if the CQC were correct and there was no role for them in this case.

“[Redacted] gave evidence to the inquest that she believed that there was a role for the CQC here as she believed that Mr Green had been in receipt of a personal care package.”

The trust has until April 30 to respond to the coroner’s report.

Whitley Court is now run by Sanctuary Supported Living. In a previous CQC report, Whitley Court was listed as an extra care housing scheme, the personal care element of which is operated by Care-Away Limited. Care-Away Limited was said to operate at Whitley Court under the trading name of Care Support – Torbay and South Devon.