Sad case of two troubled men who died alone in their Milton Keynes homes prompts safeguarding review

Two men who both died alone in their MK homes after being identified by the authorities as at risk are the subject of a major safeguarding review.

The men are only identified as Charles, who was in his early 70s, and Dylan, who was in his early 50s.

Charles died in March 2022 as result of a fire in his house, likely started when a cigarette ignited his bedding and accelerated by lighter fuel and alcohol on his bed.

An inquest later deemed his death to be accidental.

Dylan died in his flat in July 2022, shortly after being discharged from hospital. No inquest was held into his death as it was deemed to be from natural causes.

The two deaths were not connected, but the similarities in the circumstances of self-neglect and alcohol abluse have now prompted a joint thematic review by the MK Together Safeguarding Partnership (MKTSP), with the aim of developing a more system-wide approach to safeguarding other similar people.

The reviews states both Charles and Dylan had experienced alcohol abuse for many years. Both were known to services and it was understood they could be at risk of harm from poor management of their health.

Charles was described as a “lonely, very physically dependent man”, but someone who knew his own mind and was very determined to retain some control over his life.

He described himself within one social care assessment as a ‘cantankerous old man’. Diagnosed with polio as a child, he was unable to use his right arm and had limited use of his left arm following a serious car accident (for which he was imprisoned) in 2013, states the report.

He was unable to stand for long periods of time due to osteoporosis in his hips and spine and experienced pain in both legs.

Charles smoke and drank heavily and had been diagnosed with COPD and liver damage due to excessive alcohol intake.

“Throughout the review period, he received domiciliary care to support him daily...He regularly declined interventions aimed at reducing recognised risks to his health and his safety,” states the report.

“During the review period there was evidence of persistent offers to reduce risk through his carers, GP and ambulance staff. But he was adamant that he didn't want to give up smoking and drinking and stated that he is a person who likes things being done his way”.

In early February 2022 , Charles’s carers requested advice from adult social care. They were advised to raise this with his GP who, in turn, contacted the South Central Ambulance Service (SCAS) over concerns he was declining food and drink.

Later that month, his carer, GP and SCAS raised further concerns regarding a deterioration in his health and SCAS completed a paramedic review, but at Charles’s request, took no further action.

He died in the fire shortly afterwards.

Dylan had experienced periods of homelessness both before and throughout the review period, though there is evidence of “significant and persistent assistance” offered to him by MK Council’s housing department, who responded in a “timely and person-centred way” each time he risked street homelessness, states the report.

It was understood he had a conviction in 1984 and had been a successful businessman, but started drinking heavily after the financial crash in 2008. This impacted on his physical health, with numerous hospital admissions and frequent contact with ambulance.

He also had a diagnosed heart condition and was suffering seizures and cirrhosis of the liver. He was awaiting a liver transplant and was also noted to suffer with anxiety.

Dylan was sent to prison for breach of bail conditions and criminal damage following a domestic abuse incident, and he was released on licence in 2020.

But by November 2020 agencies reported he was showing sexualised behaviours, was inappropriately dressed in public areas, was making inappropriate frequent calls to 999 and was severely neglecting his environment and self-care.

Dylan was twice given temporary hotel accommodation by the council but was evicted for drinking on the premises and antisocial behaviour.

He was put forward by the council’s housing department for a supported living placement and later offered permanent housing in a new-build property. But he failed to complete the paperwork for this, so the offer was withdrawn in May 2022.

Dylan frequently called 999 because he felt lonely or ill. In 2022 he was hospitalised and discharged in July, only to call 999 again. His support worker arranged to meet him and, when he did not turn up, asked police to pay a welfare visit and requested his safeguarding risk be escalated.

"Before this could be actioned, police found him deceased in his flat,” states the report.

The report states: “MK Together’s Case Review Panel were satisfied that in both cases there was evidence of multiple agencies making persistent offers of support to reduce risk.”

But it said there as a “lack of coordinated, multi-agency risk mitigation" in both cases.

“The panel concluded there are lessons to be learned about the way in which local practitioners and agencies work together to identify foreseeable harm and prevent harms associated with self-neglect,” it adds.

The report concludes” "The reviewers wish to express their sincere condolences to members of Charles and Dylan’s family for their loss. The reviewers are also grateful to the professionals who worked with both men for sharing their insights so honestly. The efforts they made to support them and try to keep them safe were apparent.”