Safeguarding bosses warned man died after ‘agency blindness’ left him without help

Coroner presses for better health and social care cooperation after St Austell man’s death went unnoticed

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A lack of coordination between social care and health agencies allowed the death of an alcoholic man with complex care needs to go unnoticed for weeks.

The body of Colin Williams was found in a decomposed state on 9 April 2013 and the coroner’s Regulation 28 report warned that there is risk of a similar deaths occurring unless interagency working between local agencies in Cornwall improves.

The report was sent to Cornwall council and the local adult safeguarding board.

Williams, who lived in St. Austell, was known to several agencies including adult social care, his GP, police, social housing and the Royal Cornwall Hospital Trust.

In her report coroner Dr. Emma Carlyon said: “Those at the inquest gave evidence that due to the large number of potential agencies involved in his care, his age (below 65), and the fact he had variable mental capacity due to his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free or not.

“This led to agency “blindness” preventing him from accessing help/funding particularly at a time of crisis (especially when he lacked capacity due to alcoholism).”

‘Significant changes’

She said health and social care agencies must review their structure and interagency work in relation to clients with multiple care needs, in particular for adults with drug or alcohol dependency, to create a more joined-up approach and possibly introduce a key worker system.

A spokeswoman for Cornwall County Council said that since Williams’ death the authority has made significant changes to its assessment and care management service including developing locality teams.

“This change, which reflects similar changes in the health community, is designed to help build local intelligence and relationships, and support closer working between all providers of care, including the voluntary and community sector and housing organisations,” she said.

The council added that the local safeguarding adults board conducts regular reviews and audits of individual cases and also commissions an annual audit of cases by an independent reviewer who also examines the work of partner agencies and how different services work together.

The agencies involved are required to respond to the coroner’s report by Friday 11 March.

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4 Responses to Safeguarding bosses warned man died after ‘agency blindness’ left him without help

  1. Joy Stanley March 9, 2016 at 9:20 am #

    A tragedy and gross misconduct when money is prioritised befor people and their needs . Ignoring the personal budget ethics is sadly becoming second nature, is this legal

  2. Joy Stanley March 9, 2016 at 9:23 am #

    Sad and very poor practise when money is prioritised over people. Personal budgets are not being used as they were stated to be used. People are again being ignored.
    Thank you professionals for being brave enough to speak for those they are expected to serve

    • Sharon petfield March 9, 2016 at 1:46 pm #


  3. Sharon petfield March 9, 2016 at 1:46 pm #

    This is happening more and more were agencies are letting not only clients down but also there families by not turning up to provide the care and the agencies are not letting families know this which is a worry as they are supposed to be professional