Man died in squalid home; review cites missed chances

A comprehensive review by the Somerset Safeguarding Adults Board (SSAB) has identified critical failures in the care provided to a man known as Neville, who died in January 2025. Experts found substantial missed opportunities to assist Neville, who was living in squalid conditions with no food or drink available in his home.

Neville passed away from COPD exacerbated by flu, compounded by existing long-term health issues. A package of care he received between 2022 and mid-2023 was closed without ongoing support. Concerns about animals in his property were addressed by Neville voluntarily re-homing them.

Significant concerns were raised about Neville's self-discharge from hospital on December 31, 2024, a pivotal moment. The review noted a lack of professional curiosity and no mental capacity assessment, highlighting a major missed opportunity. Subsequently, no agency contacted Neville directly.

Despite severe self-neglect concerns reported by a close friend on January 1, 2025, and again by the RSPCA on January 2, 2025, no urgent home visit occurred. Instead, a mental health service signposted the friend to other agencies, delaying crucial intervention.

The SSAB has called for strengthening safeguarding criteria, improving managerial oversight, enhancing inter-agency communication, and better record-keeping. Recommendations also include reviewing hospital self-discharge procedures to ensure safeguarding risks and patient capacity are adequately considered.