Down’s syndrome man in 24-hour care died after staff failed to treat gangrene

A man with learning disabilities suffered “six months of pain” and an “undignified” death after visiting care staff failed to get his gangrene treated in time, a damning report has found.

The 56-year-old died in Newham University Hospital after living for months with an infection in 24-hour supported residential care in the east London borough.

A safeguarding review into his death found that 27 health professionals knew about his infection but did not act appropriately.

He had no “family, assertive support worker or advocate who argued that things were not improving for him”, which the report said raises questions about failings in the wider safeguarding system in Newham.

The man, named only as “Paul”, had Down’s Syndrome and lived in a one-bedroom flat where he was meant to be accompanied by a carer at all times. On at least one occasion a carer did not show up for a shift, the report found.

More than six months before his death, doctors discovered he had a “small blister”, believed to have been caused by a “yeast infection, friction burns or pressure sores”.

Later visiting doctors found he had “recurrent skin infections and MRSA”, the report said, but no referrals were made to a learning disability team.

When his infection became so bad he was bedridden, an ambulance was finally called. “Paramedics noticed a smell in Paul’s flat, consistent with necrosis [or] dying body tissue”, the report stated. “It would be an expectation that care staff and managers would recognise and act upon this. This did not happen.”

Paul spent almost two months in intensive care. He had a tube inserted down his throat four times, which destroyed his ability to swallow solid food, and underwent at least two operations to remove gangrene.

“Paul suffered pain for more than six months. He experienced indignity and discomfort in hospital despite efforts by many professionals who recognised this and tried to work together to address it,” the report stated. It added: “He never recovered from the medical problems arising from the gangrene that he developed at home. This was the reason for his hospital admission, and could have been prevented if there had been more effective earlier collaboration between professionals.”

Paul died on May 30, 2015 from respiratory failure and sepsis. Problems finding someone to investigate his death and tracking down a family member delayed the review’s publication for more than three years.

Newham council said it is working on six recommendations in the report and has introduced the National Transforming Care Programme. It will be “widening” a similar programme from March 2019. A spokeswoman for Barts Health NHS Trust said: “This was a very sad case that has seen us strengthen how we work with local partners, as well as improve our training.”