A coroner requested the review after the man, referred to as ‘Alan’, fell from a multi-storey car park in 2013, following a ‘prolonged period of abuse and intimidation by a known individual’.
An inquest into his death concluded statutory agencies failed through a ‘lack of communication’.
The review raises concerns over procedures and actions of organisations including police and mental health authorities.
Organisers of Worthing Mental Health Awareness Week, starting on Monday, have called on professionals to ensure similar tragedies will ‘never happen again’.
David Cooper, chair of West Sussex Safeguarding Adults Board, said: “The report concludes that it is not clear why Alan killed himself.
“However, ‘it may be that timely, coordinated and joined up multi-agency intervention at an early stage would have reduced the likelihood of this outcome’.”
Alan was under the care of Sussex Partnership NHS Foundation Trust, living in independent accommodation with support from a Southdown Housing officer from 2009.
The report highlights several incidents where a man, referred to as ‘John’ had abused and intimidated Alan.
But it concludes there were ‘missed opportunities’ to act in 2012, where safeguarding alerts were not raised.
The report records times when John was arrested over separate domestic abuse matters – but when it came to matters involving Alan, little action was taken.
To compound matters, when John was charged with assaults on his female partners, magistrates bailed him to Alan’s address.
The CPS should have flagged that Alan was vulnerable, the report states.
It was only days before Alan’s death, in July 2013, that John was arrested over matters relating to Alan.
Police, however, ‘failed to respond’ to Alan’s call on July 23rd stating John was outside his home. Bail conditions prevented John from contacting Alan.
Hours later, Alan fell from the car park.
The review praises a police community support officer for working hard to support Alan but notes they were not trained in dealing with such cases. Key responsibility in raising safeguarding concerns fell to Alan’s care coordinator, employed by the NHS trust.
The report states others involved felt ‘frustrated’ by the coordinator’s approach, adding their ‘failure’ to fully understand their role and responsibilities led to a lack of action.
But as the coordinator was no longer employed by the trust and did not take part in the review, report author Brian Boxall said there remained ‘unanswered questions’ over his decision making.
Following the case, the trust has created new post to provide leadership on adult safeguarding.
Safeguarding training now forms part of every staff members’ induction.
Despite recommendations for individual areas, how each agency worked together is highlighted as a key failing.
Multi-agency meetings lacked coordination, with no clear leader, while they were not minuted and actions often not followed up.
“Clear communication and coordination between agencies did not take place,” the report read.
“Individuals worked hard to support Alan but their actions were not coordinated, safeguarding alerts were not raised or progressed ...”
The report states Alan’s family ‘endorsed’ the report and recommendations.
Trust apologise over handling of case
Sussex Partnership NHS Foundation Trust has apologised for its handling of Alan’s case.
Chief executive Colm Donaghy said the organisation accepted all the recommendations of the report and would work with its partners to ‘do things differently’.
The serious case review puts the work of the trust in the spotlight, just months after it apologised for its care of Don Lock killer Matthew Daley.
Mr Donaghy said: “We are sincerely sorry for the lack of co-ordination, communication and effective multi-agency working in this case.
“We are committed to making sure staff receive the right training, support and supervision for their role, so they can provide high quality care. This report shows we need to improve the way patients and carers are involved in planning their care.”
Sussex Police, meanwhile, has admitted it ‘could have done more’ to help Alan.
Police had already referred the matter to the Independent Police Complaints Commission – and a spokesman said it took recommendations from both investigations ‘very seriously’.
“Our neighbourhood policing team had a lot of contact with Alan over three years and liaised with a number of agencies, after concerns were raised that he had been befriended by a man who was taking money from him,” the spokesman said.
“Alan made a report of theft for which the suspect was arrested and bailed.”
The force has launched a campaign to identify and support vulnerable victims of fraud, identifying agencies which could provide an advisory service to victims.
The spokesman added: “Since ‘Alan’s’ death we have reorganised our public protection unit to provide a specialist integrated service for adult and children protection and sexual offences, with robust supervision and support from partners.
“In addition a training package for officers, with advice for victims, has been made available and contact centre and front office staff have received enhanced training on vulnerability and the assessment of threat, risk and harm.
“As well as mental health practitioners providing support to neighbourhood policing teams the force is trialling a mental health practitioner being co-located in the control room, providing fast time advice and access to medical records to allow for meaningful assessments. This is an innovative pilot and works towards the Chief Constable’s aims to work with partners to protect vulnerable people.
“A process in managing vulnerable people brought in after Alan’s death by police in Adur and Worthing has been rolled out across the force.
Awareness week to highlight ‘heartbreaking’ case
Lessons must be learned from Alan’s case, a co-founder of Worthing Mental Health Awareness Week has urged.
Tarring county councillor Bob Smytherman, who helped set up the awareness week, said volunteers would be calling on mental health professionals to learn from the serious case review and its recommendations.
He said: “This report makes truly heartbreaking reading for the family of such a vulnerable man as Alan and it’s clear he was systematically failed by numerous professionals charged with caring for him.
“I am especially disappointed that his care coordinator from Sussex Partnership Foundation NHS Trust was not called to provide his valuable evidence which would have been vital to ensure all the lessons can be fully learned.
“Our thoughts and prayers go out to his family at this very difficult time.”
A series of free events will be held between Monday and Saturday.