Woman calls for lessons to be learned from brother’s death
FRUSTRATION THAT HIS ALCOHOL DEPENDANCY WASN’T ADDRESSED BY SERVICES
A LOVING sister has expressed hope that lessons can be learned after the death of her much-loved brother who neglected himself after turning to alcohol “to forget everything”.
She told safeguarding investigators in Kirklees that she felt frustrated that her brother was simply ‘signposted’ to services and that his repeated behaviour was not fully addressed.
Her concerns are contained within a safeguarding report of her brother’s death in his 40s after periods of sleeping rough in woodland, in his car and in various accommodation, including hotels, in Huddersfield, Leeds, Sheffield, Halifax, and Harrogate. After years of neglecting himself, he was found dead in his council flat.
During his final years, he was found living in unsanitary conditions, was self-neglecting, unresponsive and intoxicated.
The man, who has not been named, is referred to as Adult N in a report published by Kirklees Safeguarding Adults Board, which says that opportunities were missed to get to the bottom of his problems and fully address them.
It says that, from March 2020, Adult N had lived in Kirklees and had died on June 17, 2020. His sister said her brother was kind, university-educated and had travelled the world with friends and for work.
On the surface, he appeared to be happy but it was difficult to know how he felt on the inside, she said. He had become dependent on alcohol which his sister described as a coping response “to forget everything.”
Report author Professor Michael Preston-Shoot included a chronology of events within his review which detailed numerous visits to A&E departments as well as interactions with police, GPs, the ambulance service, housing providers and substance misuse workers.
He was found on numerous occasions in a collapsed state, covered in vomit and urine and, on occasion, with injuries including a fractured skull.
He had managed to get sober several times and find work as well as pay for rehab services in London and Blackpool. In 2017 he had accessed services in Huddersfield.
Professor Preston-Shoot says that ‘repeated patterns’ of behaviour “does not appear to have prompted an adult safeguarding concern.”
At times, he was said to be drinking three bottles of vodka a day and was walking around barefoot, with blisters on his feet. He had been staying in hotels but had been evicted for using his room as a toilet. He had been found in a car in Halifax and had used that as a toilet.
The report into his death came about because of the possibility of neglect and/or acts of omission by agencies involved with him.
The author says: “In the final two months of his life, when in Kirklees, no mental capacity assessment was undertaken.”
The man’s sister expressed frustration that her brother was “just signposted to services, with the repeating pattern not being picked up and addressed.”
She described five years of trying to find him, of times when he would not say where he was, of occasions when he would pass out for days. She believed that family members had been left to cope and that they had felt helpless.
The report author says: “What is striking in this case is the absence of multi-agency meetings across the three areas where Adult N presented repeatedly with problems associated with homelessness, alcoholdependence, and self-neglect. The result was an episodic, disjointed approach to meeting his needs.”
There were missed opportunities, according to the author, with staff assuming others would be the ones to refer him for assistance.
“His sister has expressed the hope that this review will help raise awareness of the need for a coordinated and collaborative multi-agency approach to alcohol-dependence and self-neglect.”
Five days before his death, a housing officer undertook a welfare check and found him in his room, unresponsive and cold, heavily saturated in urine. Initially, the officer and the ambulance crew thought that he had died.
Yorkshire Ambulance Service took him to Huddersfield Royal Infirmary where self-neglect and intoxification were identified. He was discharged once medically fit. No risk management multi-agency meeting appears to have been considered, the report noted.
Housing Solutions submitted a formal self-neglect referral on June 16, the day before he died, June 17, 2020. The cause of death was acute fatty liver and chronic alcoholism. He had passed away in his room.
Following the report’s publication, Robert McCulloch-Graham Chair of the Kirklees Safeguarding Adults Board said: “Firstly, we would like to offer our condolences to the family of the deceased at this difficult time.
“A Safeguarding Adults Review was commissioned following the death of an adult referred to as Adult N. The aim of the review was to examine whether there were any lessons to be learned for the partnership of services that tried to assist in this very sad and tragic case.
“KSAB is absolutely committed to improving practice and establishing ways that local and regional agencies can work together effectively, providing the highest possible standards to safeguard adults at risk in our community.”