Coroner says more deaths of vulnerable adults with complex needs could be avoided

An assistant coroner in Greater Manchester has written to the Secretary of State for Health and Social Care urging that action should be taken to prevent future deaths of adults with complex needs.

The warning comes after an investigation into the death of Jordan Peter Clare, aged 22 years. The investigation, which concluded in October last year, after Jordan took his own life.

“Jordan had diagnoses of ADHD, attachment and conduct disorder and suffered from anxiety and depression,” Adrian Farrow, Assistant Coroner, for the coroner area of Greater Manchester South, writes in his report. “He had historically been addicted to Class A drugs and this led him into conflict with the criminal law and with his family which had resulted in a restraining order which restricted contact with his family and periods in custody.

“He had significant support from a number of sources: he was supervised by the probation service and the police ‘Spotlight’ team; he was working with Mosaic – an organisation who assist with drug misuse; the local authority Leaving Care team provided assistance on a voluntary basis as he was over 21 years old. The local authority housing organisation provided him with the tenancy of a flat in Marple and as part of that tenancy, he had an Offender Support Worker who assisted him. He had regular contact with his General Practitioner.

“Notwithstanding the involvement of the various agencies there was no single individual or agency responsible for the co-ordination of the package of care, support and resources. Whilst there was sharing of information between some individuals involved, it was not structured, formalised or supervised. In practice, the Housing Offender Support worker, whose role did not require any formal social work or mental health care qualifications became the person upon whom Mr Clare relied.

“An issue between Mr Clare and a neighbour developed over a period between June 2020 and his death on 26th August 2020, during the latter stages of which, he began to voice intentions to take his own life. On 26th August 2020, in a series of calls and messages to the police, Housing Officer and the Offender Support Worker, Mr Clare expressed extreme distress about the apparent lack of progress about the dispute with his neighbour and progressively, made threats to take his own life, which he did during a final call to the Housing Offender Support Officer by suspending himself by a ligature at his home.”

However, during the course of the inquest, the evidence revealed matters giving rise to concern, the coroner said.

“The Inquest heard evidence from the Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council. She highlighted a long-standing gap in provision, which was described as extending across most if not all local authorities, for vulnerable adults who have complex needs, but who do not fall into the existing framework of social services, Care Act provision or formal mental health supervision,” Mr Farrow said.

“The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care coordinator. The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding. Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.

“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action,” Mr Farrow concluded.

The Secretary of State, Steve Barclay, is now under duty to respond to this report within 56 days with a response which must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise he must explain why no action is proposed.