A safeguarding review into the death of a 54-year-old Oldham man has identified 'important lessons' after finding he may have been exploited by his family.
The Oldham Safeguarding Adults Board carried out a review into the circumstances leading to the death of a man referred to as Michael. He died at Royal Oldham Hospital following what is believed to have been an intentional overdose in May 2023.
Review findings
The board examined the case to 'better understand the care and support provided to an adult man in the year before he sadly passed away'. Michael was described as having experienced a series of mental health crises requiring urgent medical responses, and concerns were raised that he may have been exploited by family and friends.
The review found several areas of good practice, including the response of healthcare professionals on multiple occasions, as well as follow-ups from his GP. Oldham council was praised for the support provided during Michael's periods of homelessness.
However, the review also found 'some weaknesses and limitations' linked to the organisation of certain healthcare services, as well as 'high demand on limited resources, particularly in the mental health arena'. The board said Michael's case was 'therefore potentially not a unique set of circumstances' and there was 'not an easy solution to the various system problems that undermined the ability of practitioners to join-up the care that Michael received'.
Mental health and exploitation concerns
While Michael had a number of physical health issues, including heart problems, the review said support services only became aware of his mental health problems from March 2022. A number of factors were believed to have contributed to this, including homelessness following a marital breakdown, the death of two siblings, and 'numerous incidents of suspected exploitation by people he was staying with'.
Contributions from family members were considered as part of the review, but many were not contacted 'because some had made unverified allegations against him, whilst others were alleged to have been involved in financially exploiting him'. While some of these allegations were reported to the police, Michael reportedly did not respond to police enquiries.
In March 2023, Michael's bank raised concerns of 'likely financial exploitation by a family member' and that Michael had claimed one family member would only allow him to collect his belongings if he paid money.
Report recommendations
The report said: "Having stable, trusted relationships and a home are often protective factors in times of difficulty and Michael did not seem to have any of these in the final year of his life, which may have undermined his resilience and ability to cope.
"This lack of protective factors could therefore have compounded his vulnerability, his anxiety about his health, his suicidal thoughts and the intent to end his life."
It is suggested Michael's mental health issues may have reflected the situation around him and was prompted by those close to him. On the day he died, his behaviour was 'markedly different' and he was 'uncharacteristically erratic and aggressive'.
In March 2022, the review found Michael was admitted to a Tameside mental health ward following a 'large overdose' and the events 'appeared to coincide with anti-social behaviour' linked to the property of a family member. He was unable to live there any longer after an anti-social behaviour order was imposed by landlord First Choice Homes Oldham.
Over the following months, Michael ended up in Royal Oldham Hospital as a result of chest pain and heart issues and described 'living here, there, and everywhere' during that time. The review said he took another overdose in January 2023.
The review made recommendations on how service-providers can improve. These include better communication around relevant care pathways and services, work with the Oldham Suicide Prevention Partnership about the role of physical prescription medication in suicide, developing best practice guidance for prescribers, and seeking assurance from partners that anyone prescribing medication has policies that recognise potential suicide risk.
Other recommendations included improving communication, working with partners to raise awareness of certain health conditions, and improving guidance. The board was also recommended to seek assurance from Pennine Care NHS Foundation Trust that its risk assessment processes and practices for adults at risk of suicide are in line with NHS England best practice.
Dr Henri Giller, the Independent Chair of Oldham Safeguarding Adults Board, said: "We are deeply saddened by Michael's death and extend our sincere condolences to everyone who knew and cared about him.
"Our thoughts remain with those affected by his loss. This review highlights the significant challenges Michael faced in the final years of his life, including serious physical health problems, deteriorating mental health, housing insecurity, and concerns about exploitation.
"While many professionals worked hard to support him and provide care during multiple crises, the review identifies important lessons about how services share information, coordinate support and respond to people experiencing both physical and mental health difficulties at the same time.
"We accept the findings of the review and are actively implementing its recommendations."
