‘John’ serious safeguarding review

An elderly man spent days on the floor of his HMO while maggots infested wounds in his legs before he was discovered and later died, a report has found.

The 69-year-old from Oldham, named ‘John’ in a safeguarding review, was discharged from hospital just two weeks before the fall that led to his death. The recently published report found the local authority and medical professionals at Royal Oldham Hospital ‘missed opportunities’ to support John.

Prior to his death, John was treated for severe malnourishment and an acute kidney injury. At the time, he shared with staff that he ‘did not feel safe in his home’, as he lived in a HMO with five other people, all of whom had serious alcohol and substance abuse issues.

John was told a housing application was ‘unlikely to be accepted’, and ‘possibly as a result of this information’ agreed to be discharged from the hospital into the HMO, the report said.

But hospital staff were unaware of the extent of the horrific conditions John faced at home. He had no central heating or hot water due to a broken boiler. There was no way to reheat or cook food as there was no functioning microwave, kettle or cooker at the property. And John struggled to access the shared bathroom on the first floor due to mobility issues and the state of the facilities.

Some of this information had previously been flagged to the adult social team, which should have been shared with health professionals before the discharge, the report found.

During his hospital stay, he was also referred to the council’s adult social care team – his third referral in just over a year – and to Age UK. While staff did visit John’s address and call after he returned from hospital on October 18, they failed to inform other agencies that their attempts to contact him had been unsuccessful.

It emerged later that John had fallen at home soon after his hospital discharge and was unable to call for help. For several days, he remained on the floor, developing pressure ulcers and becoming ‘covered in urine and faeces’. When his daughter discovered him on November 5, there was ‘evidence of maggots on his lower legs’. John was hospitalised but passed away on November 7.

The recently published report found there were ‘several missed opportunities’ to fully assess John’s care needs and follow up on safeguarding concerns after his hospital discharge.

The report also found: “There is a lack of evidence to support that there was sufficient communication between hospital teams when caring for John. It is unclear if medical teams discussed with ward staff if the safeguarding concern was addressed and if discharge was going to be ‘safe’.”

The report also noted that John might have felt ashamed because of the poor living conditions of his home, and as a result was reluctant to ask for or accept help that required social workers to enter his home. It reflected there were further ‘possible missed opportunities’ for the council’s housing team ‘to involve them in addressing whether the landlord who owned the property could have been made to address the poor living conditions at the property’.

Dr Henri Giller, the Independent Chair of Oldham Safeguarding Adults Board, said: “We extend our sincere condolences to the family and friends of John following his death. 

“The safeguarding review identified areas where care did not meet the expected standards, and we are deeply sorry. The review has been completed, and we have taken the findings extremely seriously.  

“Actions have been taken to strengthen how we support and safeguard adults who may be vulnerable. This includes improving communication and coordination between services, particularly when planning hospital discharges. 

“Our priority is to learn from this case and to continue improving services to reduce the risk of similar incidents occurring in the future.”
A spokesperson for the Northern Care Alliance, who run Royal Oldham Hospital,  added that the Trust is working closely with the local authority to improve patient experiences and safety after discharge from hospital.