Opportunities to protect homeless man who died in Wellingborough were missed, review finds
He was found dead in a hotel room just over a week after he was last discharged from hospital
Agencies missed opportunities to protect a homeless man and rarely understood his pattern of crises, a review into his death has found.
Jonathan Upex, 46, was found dead by a social worker at Wellingborough's Euro Hotel in Midland Road on New Year's Eve in 2019, just over a week after he was discharged from hospital.
Jonathan, known as 'Jon boy', had contact with several agencies including police, councils, hospitals and a night shelter in the year leading up to his year with more than 700 entries recorded and more than 40 attendances at emergency departments.
But a review of his death, commissioned by Northamptonshire Safeguarding Adults Board, found chances to protect him were regularly missed, "often as a result of professional preconceptions of care and support needs and risk".
His family now wish practice improvements are made so that agencies work better together to safeguard those suffering from similar experiences and challenges to Jonathan. A total of 11 recommendations have been made to act as a 'catalyst for change'.
Tim Bishop, independent chair of Northamptonshire Safeguarding Adults Board said: “Northamptonshire Safeguarding Adults Board commissioned this independently-led review to examine the circumstances surrounding the death of 46-year-old Jonathan, who was living in a hotel in Wellingborough at the time of his death on December 31, 2019, following a hospital discharge. Jonathan had a range of care and support needs.
“The review found there had been over 700 individual entries recorded by a number of agencies within a 12-month period including a high level of contact with both statutory and community-based services, including police officers, probation workers, housing and homelessness professionals and social workers, as well as attendances at hospital emergency departments and admission to hospital as an inpatient.
“Whilst there were examples of positive practice, including many examples of determined efforts to help Jonathan, overall the review found that opportunities to protect Jonathan were missed, often due to a lack of planning, communication and co-ordination between agencies causing Jonathan’s repeated pattern of crises to be rarely acknowledged or understood.
“The review has identified eleven recommendations which aim to act as a catalyst for change so improvements can be made to reduce the likelihood of this happening again and the board will continue to review and monitor these to ensure the agreed actions are implemented.
“On behalf of Northamptonshire Safeguarding Adults Board, I would like to offer our sincere condolences to Jonathan’s family. We would also like to thank those family members who felt able to contribute to the review. They were clear in their wish to see local agencies learn lessons from their tragic loss, to better safeguard adults in Northamptonshire in the future.”
Jonathan, whose hopes and aspirations centred on starting a family of his own, securing work and buying a house, was considered to have multiple vulnerabilities and risks, having been homeless and sleeping rough including during freeing winter temperatures.
But the review found that, despite regularly coming to the attention of a number of statutory services with significant physical and mental health conditions, his housing, health and care and support needs, including risks, were not readily acknowledged.
Incidents of crisis were noted, including being found to be 'obviously malnourished', wanting to get arrested because he was cold and homeless and being found wandering in the rain.
He had been denied entry to a night shelter because of previous disruptive behaviour, and it was noted that he 'did not appear to be in priority need for housing' between December 2018 and June 2019.
The review found it was 'surprising' that he was not judged as significantly more vulnerable than an ordinary person facing homelessness and that it was a missed opportunity to intervene.
Jonathan, who was well-liked and known for his loyalty and willingness to help others, was taken to Northampton General Hospital on October 14, 2019, and placed in an intensive treatment unit before later being transferred to a ward.
On December 18 he was discharged and temporary accommodation was arranged at the hotel. He was discharged with medication but no money, bank account, phone or ID.
Three days later he suffered a fall and returned to the hospital, the last time he was seen by professionals prior to his death, and later discharged.
The review found there was a missed opportunity for 'purposeful multi-agency working' around his final stays in hospital.
It said: "When people fall through the cracks or have no choice and control in the discharge planning process, they will usually return to hospital quite quickly, which is what happened on December, 21, 2019 when Jonathan returned to hospital having suffered a fall in the hotel room.
"At the point of hospital discharge, in particular on December 21, 2019, there was a distinct lack of understanding the risks Jonathan would face, including exploration of the likelihood and severity of harm he could incur.
"There was no consideration of the available options to protect Jonathan, or exploration with him about the impact that his choices could have on his wellbeing. Undue confidence was placed on his ability to care effectively for himself and there was a failure at working collaboratively to understand risk, with little to no value given to levels of safety following discharge(s) from hospital."
Social services tried to visit him on December 23 but could not gain entry. His friend Wendy Steele took him lunch on Christmas Day, but raised the alarm when he failed to respond when she went back the two following days to see him.
She called social services, who referred her to police, who referred her back to social services. Police said they had no grounds to exercise powers of entry as there was no immediate threat to life.
Speaking after his death, Wendy said: “If someone had gone and checked on him this might not have happened."
The Safeguarding Adults Review has now provided 11 recommendations to agencies including practice reviews and audits.