Man died in 'squalid' home with no food or water

There were significant missed opportunities to help a man who died in a "squalid" home with no food or water, a review has concluded.

Experts at the Somerset Safeguarding Adults Board (SSAB) have called for changes to how people at risk of self-neglect are cared for after the death of the man, who its report names as Neville.

He died in January 2025 from COPD (chronic obstructive pulmonary disease) complicated by flu, alongside existing long-term conditions, the report said.

Professor Michael Preston-Shoot, independent chair of the SSAB, has said he is working with all organisations involved to ensure learning becomes "embedded in daily practice".

The review has been shared with a number of agencies, including the NHS Integrated Care Board, Somerset NHS Foundation Trust, housing employees within Somerset Council, the council's adult social care service and Avon and Somerset Police.

The report said Neville, who had a history of significant long-term health conditions, received a package of care between 2022 and mid-2023 but it was closed with no ongoing support in place.

Concerns had also been raised to the RSPCA about animals in the property, which were voluntarily re-homed by Neville, who had struggled with periods of low mood due to his worsening health.

"By early January 2025, he was living in conditions described as squalid, with no food or drink available in the home," the report said.

Neville was taken to hospital by ambulance from a friend's home on 31 December 2024 after becoming unwell.

He later self-discharged on the same day, a moment described as "pivotal" in the lead up to his death.

The report said there was "no evidence that staff explored Neville's understanding of the risks associated with leaving hospital" or undertook a mental capacity assessment before allowing him to leave, a move which was noted as "significant".

"The lack of professional curiosity at this point was highlighted as a missed opportunity," the report said.

After Neville's discharge, no agency made direct contact with him and despite severe self-neglect concerns raised by a close friend on 1 January to the First Response mental health service and again by the RSPCA on 2 January, no urgent home visit took place.

Instead of escalating the friend's concern or passing it directly to the council's adult social care team, First Response signposted his friend to adult social care and the GP.

Preston-Shoot said the SSAB, set up to prevent the neglect and abuse of adults, existed to "protect vulnerable people" and "to make sure lessons are learned".

He said Neville's story had "highlighted the need to truly understand mental capacity linked with self-neglect".

The changes recommended by the SSAB include that agencies strengthen the interpretation of safeguarding criteria so serious concerns trigger formal enquiries.

The report also called for greater oversight on major safeguarding decisions from managers, improved communication between agencies, and record keeping of key documents explaining decisions and assessing risk.

A review into how hospital self-discharge procedures are being implemented to make sure staff are considering safeguarding risks as well as the patient's capacity to discharge themselves was also recommended.

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