On 6 January 2012 ‘Robert’ was found dead in his room at a hotel in Harrogate. A coroners inquest subsequently recorded a verdict of accidental death due to intoxication by morphine, a painkiller that had been prescribed to him – the man had been dead for 4 days before he was found.
Robert was a long term rough sleeper, who had initially come into contact with agencies on 21 December 2011 when he had requested support to find accommodation.
A local charity had made requests to Harrogate Borough Council and North Yorkshire County Council to find him emergency council accommodation, but all the requests were refused. The charity took the decision to pay for him to sleep in a hotel, where he died shortly afterwards.
There was concern that a vulnerable adult in receipt of health or social care had an unexpected death or died in unusual circumstances which prompted North Yorkshire Safeguarding Adults Board to undertake a Serious Case Review which has now been published.
A Serious Case Review into the involvement and contact of the public agencies in North Yorkshire with the man has been conducted by an independent author and has now been published.
A Serious Case Review also outlines whether there are any lessons to be learned from public agencies’ actions.
This review recommends fourteen actions or learning points for the agencies involved and for the Safeguarding Adults Board. Individual agency recommendations have either been implemented or are on target for implementation.
The Executive Summary Report outlines the circumstances surrounding the man’s death, which spanned a short period between 21 December 2011 and 6 January 2012 and involved contact with a number of statutory agencies in the Harrogate area, none of whom had previously had contact with him.
Jonathan Phillips, independent chair of North Yorkshire Safeguarding Adults Board, said
This is the first Serious Case Review to be considered by North Yorkshire Safeguarding Adults Board and is unusual in that it focuses on a very short period of the man’s life and that his involvement took place over the extended Christmas and New Year holiday period
We accept the recommendations in this report fully as they will further professionals’ understanding, support wider knowledge sharing and improve services for homeless people in this complex and unique area of adult social care.
There are a number of lessons to be learned for all the agencies involved, in particular there is a need for greater understanding and information sharing across agencies on both homelessness legislation and its interaction with community care and the duty to take vulnerability into account in relation to homelessness
The Executive Summary Report can be viewed at: www.northyorks.gov.uk/safeguardingadultsboard
A spokesperson for Harrogate Borough Council said:
Housing officers at Harrogate Borough Council would like to take this opportunity to once again offer their condolences to the family.
The finding of the coroner was that the death was as a result of an accidental overdose of morphine-based painkillers and not directly related to the accommodation.
This gentleman was an itinerant rough sleeper who approached the council for accommodation, presenting as homeless. The decision at that time was that the council did not have a duty to provide him with temporary accommodation under homelessness legislation.
However, the serious case review did identify some important lessons with regard to both our own internal procedures and arrangements for working with other agencies, including adult services, health and the voluntary sector.
The council immediately carried out its own internal investigation and we have reviewed and revised our procedures to improve the way cases like this are dealt with in the future.
The changes implemented by Harrogate Borough Council include:
- a new contract for out of hours response
- revised internal procedures for assessing vulnerability
- refreshed training for staff involved in dealing with homelessness and specifically rough sleepers
- reviewed arrangements with the voluntary sector, health and adult services
The Harrogate Borough Council spokesperson concluded:
The council is fully committed to meeting its responsibilities under homelessness legislation and we will continue to work with the adult safeguarding board and other partners to deliver an action plan agreed as a result of this serious case review.
The report has concluded that neither the Harrogate Borough Council or North Yorkshire County Council were responsible for his death, but the handling of his case was unsatisfactory. It also urges both councils to review policies for dealing with vulnerable people.