'Opportunities missed' to save homeless man, review finds

Jonathan Upex was found dead by a social worker and hotel staff member on New Year's Eve 2019

Opportunities were missed to protect a homeless man who died despite being known by councils, police and hospital workers, a review has concluded.

The Safeguarding Adult Review was commissioned following the death of Jonathan Upex in a Wellingborough hotel in 2019.

It found more than 700 case records had been lodged against his name in a year.

Northamptonshire Safeguarding Adults Board said repeated crises were "rarely acknowledged or understood".

Mr Upex died on 31 December 2019 while living at Euro Hotel in Midland Road, Wellingborough, following a hospital discharge.

The 46-year-old, who suffered with bipolar disorder, had been found by a social worker and a member of staff.

East Northamptonshire Council had been paying for his stay as he had nowhere else to sleep.

Mr Upex was found dead in his room at the Euro Hotel in Wellingborough

The review said he had a range of care and support needs and had "experienced abuse and neglect, including self-neglect".

More than 700 individual entries relating to him had been recorded by several agencies within a year, including more than 40 visits to A&E at Kettering and Northampton hospitals.

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The review said Mr Upex "had a high level of contact" with police officers, probation workers, housing and homelessness professionals and social workers.

It said: "This represented a high level of involvement from agencies and the records showed an elevated degree of concern for Jonathan's wellbeing, including risk to life."

Despite this, the review found opportunities to protect him "were often missed".

Mr Upex had increasing problems with his mobility, continence and ability to concentrate and remember appointments.

As a result, the review said it was "surprising" he had not been judged as more vulnerable than "an ordinary person faced with homelessness".

It added: "It would not be reasonable to expect Jonathan to physically attend all appointments given his health issues, financial troubles and having no means of contact without substantial support."

Other failures included a lack support relating to housing, a mental capacity assessment which caused him "frustration and distress" and a lack of review of case records regarding his exclusion from emergency night shelters.

The report said this meant he was "continuously unable to seek respite from the streets, and there was a sense of Jonathan being permanently excluded".

It also found "multiple notifications of concern" were submitted to Northamptonshire County Council's adult social care and adult safeguarding teams.

The review said Jonathan Upex's "life course exemplifies that of an adult facing multiple exclusion homelessness"

These included a record noting significant concerns he would die if agencies did not intervene.

The independent chair of Northamptonshire Safeguarding Adults Board, Tim Bishop, said: "Opportunities to protect Jonathan were missed, often due to a lack of planning, communication and co-ordination between agencies causing Jonathan's repeated pattern of crises to be rarely acknowledged or understood."

Both Northampton and Kettering hospitals said the care given to Mr Upex was "appropriate" but it was clear more could have been done to raise concerns about his overall welfare.

Kettering Hospital's director of nursing and quality, Leanne Hackshall, said the hospital would be expanding participation of a meeting held between A&E clinicians and the mental health team to include representatives from housing, homelessness and addiction services.

In a joint statement, Northampton Hospital's director of nursing, midwifery and patient services and executive director for safeguarding, Sheran Oke, said the hospital works with colleagues in mental health, substance misuse, housing and adult social care to ensure "patients with complex needs receive a thorough assessment".

Northamptonshire County Council Cabinet member for adult social care, Ian Morris, said: "Although considerable efforts were made to support Jonathan, unfortunately the review found that opportunities were missed."

He said work was already under way to address the issues raised, including improving communication so that information was shared between different agencies.

He added dealing with multiple exclusion homelessness was "challenging and complex" and the council was looking to "find new ways of tackling these challenges".

Leader of East Northamptonshire Council. Steven North, said the authority was "in the process of reviewing our decision-making processes regarding priority housing need referrals".

He added the upcoming move to the new North Northamptonshire unitary authority would "provide opportunities for much closer working between agencies on complex cases".