A botched safeguarding enquiry into similar injuries sustained by two learning-disabled men made it impossible to clearly establish their causes, a scathing report has found.
The safeguarding adults review (SAR), published this week by West Sussex Safeguarding Adults Board, identified a series of errors in agencies’ responses to broken legs suffered by Matthew Bates and Gary Lewis within a 24-hour period at the same care home.
The two men, both residents of Beech Lodge, near Horsham in West Sussex, were hospitalised with femur fractures during the morning of 1 April 2015.
Sussex Health Care, the company that runs Beech Lodge, has since become the subject of separate ongoing investigations by the police and Care Quality Commission into a number of reported deaths at its homes.
The SAR found that poor handling of the initial safeguarding process led to a confused and ineffective enquiry into Bates and Lewis’s injuries.
The police were involved too late, it found, while allowing Sussex Health Care to take a lead role into determining events at one of its homes undermined the investigation’s credibility. Suspicions voiced by Bates and Lewis’s families, around collusion between agencies, had been left “difficult if not impossible to rebut”, the review said.
The report’s author, retired police superintendent Brian Boxall, said he had “no doubt” that the matter would have been handled differently had children been involved. “This case demonstrates how the approach to injuries inflicted on vulnerable adults still has a different, more cautious approach, leaving adults at risk,” the report concluded.
Bates and Lewis had both been resident at Beech Lodge since 2003. Bates, 30, was from Surrey, while Lewis, 63, came from Camden. Both men have severe learning disabilities as well as physical disabilities.
In 2013, an internal review by Sussex Health Care had identified issues around the use of hoist slings at Beech Lodge, as well as a number of other issues including with recruitment. CQC inspections that year and in June 2014 found the home to be compliant with quality and safety standards – but the latter inspection noted Beech Lodge’s lack of a registered manager. A July 2015 inspection found this had again been the case from late 2014 onwards, after Sussex Health Care failed to notify the CQC about changes to an existing manager’s role.
On 29 March 2015, minor bruising to Lewis’s face was noticed by Beech Lodge staff and reported to West Sussex council’s adults’ services. The day after, care home handover notes indicated that Lewis was taken to an unspecified hospital for a precautionary hip X-ray – for which no reason was recorded – but was not seen as no appointment had been made.
On 31 March, the day after returning from a home visit, it was noted that Bates’ right thigh was swollen after he had been hoisted to his bed. The hoisting was carried out by two staff, but Bates had been taken to his room by just one person, who initially said “he did not need any help”, the review said.
Bates was given paracetamol but no further action was taken until the following day, when a nurse expressed concern that his leg could be fractured or dislocated. He was then transferred to hospital by ambulance.
On the morning of the same day, 1 April 2015, two carers prepared to hoist Lewis onto a shower trolley. “One of the carers then left the room and the second carried on with the hoisting procedure alone,” the review noted. After showering it was noticed that Lewis’s “breathing had altered” and his upper left thigh was swollen – and he too was taken to hospital in an ambulance.
After Bates and Lewis were admitted to hospital, an emergency department consultant quickly flagged concerns as to the two men’s “unusual” injuries.
“I do not think these fractures would have occurred spontaneously and do have concerns that they may have been sustained as a result of non–accidental injury,” the consultant wrote. Two safeguarding alerts, one for each man, were created, and forwarded from a hospital social worker to West Sussex’s adult services community learning disability team.
The review noted the prompt recognition of “potential criminal acts” by hospital staff. “The police should have been the lead agency and should have been involved at an early stage,” it said.
Both referral forms suggested the police had been informed but gave no further details – information that West Sussex’s adult safeguarding duty team could have checked but did not. “It has now been established that the police had not been informed on the day by any agency, and did not become aware of the incidents until 9 April 2015,” the review said.
It noted that learning from London SARs published in 2017 drew attention to the importance of early information sharing with police by other agencies, to ensure that opportunities to gather forensic evidence were not missed. The referral forms’ similar omissions, despite being completed by different people, suggested sloppy institutional practice, the review added.
While Section 42 enquiries were subsequently commenced by the community learning disability team, the SAR said they were hampered by assumptions “from an early stage” that manual handling had been the probable cause of the two men’s injuries.
Prior to an initial safeguarding enquiry meeting, which took place on 10 April, investigations were also mostly undertaken in-house by Sussex Health Care – and specifically by Beech Lodge’s manager. The firm’s involvement, given the potential conflicts of interest, “should have been minimal”, the review said.
The concerns of the hospital consultant were not presented at the initial safeguarding enquiry meeting. Nor were family members invited to it – stoking fears of collusion between agencies, and that Sussex Health Care was in charge. These suspicions were only deepened after contradictions in evidence later emerged, including from one agency worker believed to have been present with Lewis, who subsequently denied having been at Beech Lodge at all that day.
The safeguarding enquiry ultimately failed to provide a clear explanation as to how Bates and Lewis’s injuries occurred. It concluded that they were “probably” caused because of single-handed manual handling, not in accordance with guidelines in place at Beech Lodge.
“Failing to investigate the injuries suffered by Matthew and Gary in a thorough and timely manner, led to a confused enquiry which was led at an early stage, by the assumption that the injuries were caused by manual handling, and reached a conclusion that is not certain and not supported by clear evidence,” the SAR found. “This has let Matthew and Gary down and has led families not to have any trust in what agencies have said in response to their many questions.”
Orchid View connections
The SAR made a total of 19 recommendations, 14 of them to West Sussex Adult Safeguarding Board. The majority of these relate to improving reporting and record-keeping practices, as well as ensuring the involvement of the police where appropriate, and that staff involved in conducting investigations are appropriately trained.
The SAR also drew parallels between the Beech Lodge cases and a 2014 review, carried out in the wake of deaths at the Orchid View care home in West Sussex. It noted that the Orchid View review had also highlighted concerns around regular changes of care home manager.
Annie Callanan, the independent chair of West Sussex Adult Safeguarding Board, said the board “took note” of the connections with Orchid View.
She said that it was “important to retain focus” on the impact that the injuries had had on Bates and Lewis, both of whom had to endure long hospital stays and relocation from a settled home.
“We will look at the specifics of the cases involving Matthew and Gary and work through all recommendations to make sure we, as a board, meet our commitment to improving services,” Callanan said.