The tragedy of a homeless man who froze to death outside a church was both “predictable and preventable”, an investigation has revealed.
More than three years after 33-year-old Tony Porter’s death sent shockwaves through the city, experts at the MK Safeguarding Board have finished their lengthy review of the case.
And they have criticised all the authorities for letting such a vulnerable adult slip through the net so many times.
The report, which refers to Tony as Adult B , describes how, after years of alcohol and drug misuse, he had received a diagnosis of autism.
But the assessment that could lead to him getting specialist supported housing for the autism was not completed by the council before he died.
Meanwhile concerns from other professionals, including police and doctors, were not sufficiently shared and acted upon, the report states.
Tony was a regular at Milton Keynes hospital and had suffered “life-threatening alcohol withdrawal seizures” in the past.
He was well-known to police and the probation service and had been asked to leave the YMCA because of his drinking problems. He had also lost two tenancies over the year due to rent arrears and antisocial behaviour.
Just weeks before his death, the police medical examiner wrote a concerned letter to the courts asking them to consider a Mental Health Act order for Tony .
The letter described how everybody who encountered Tony found him “child-like” with no ability to take control of his situation or change it.
It warned he was back living on the streets and drinking heavily.
The safeguarding report states: “This behaviour put him at considerable risk... (The letter) suggested unless his disability was quantified he was likely to continue in activities that risked his health and his life.”
On February 11 2016 the pastor of the church of Christ the Cornerstone at CMK found Tony lying face down.
Paramedics were called and he was certified dead. A inquest later gave the cause of death as hyperthermia.
The safeguarding report states: “Adult B was known by practitioners to be vulnerable...You would think ‘how many more times’ should a person displaying such concerning behaviours and worrying health concerns have before a professional meeting is called to consider his case?”
It added: “Opportunities to carry out a risk assessment or make a referral to escalate his case earlier were missed on many occasions.
“ The likelihood of a tragic outcome for Adult B was high even before it was known he had autism. It is suggested in Adult B’s case it was both predictable and preventable.”
MK Council has now significantly improved its procedures for homeless people all over Milton Keynes.