Homeless man who died in hotel was failed by the authorities

Jonathan Upex, 46, repeatedly sought help before his death at the Euro Hotel, Wellingborough, on New Years Eve 2019

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By Sarah Ward

In September 2019 Jonathan Upex was sleeping rough outside Nationwide in Market Street, Wellingborough. He was chronically ill and had mental health problems. Befriended by some concerned residents, including street pastor Wendy Steele, they bought him food and clothing and tried to help him with doctors appointments and to secure housing.

But in October he disappeared, returning to the town again on December 18 after being discharged onto the streets from Northampton General Hospital after a ten-week stay in which he was found to have a traumatic brain injury and was treated for suspected meningitis and inflammation of the brain.

Fourteen days later he was found dead at the town’s Euro Hotel, where he had been put up by the housing department as a temporary stop gap.

Wendy, who had seen him again on Christmas morning after he came and sat at the back of her church, visibly hungry and begging for sweets, had taken him a festive lunch later that day and arranged to go back to see him at the hotel on the 27th. After not being able to contact him on that day, Wendy called the police and raised concerns for his safety but was told they could not force entry as there was not sufficient grounds.

He was later found on December 31st by a social worker. He had died of heart disease.

Last year a safeguarding adults review was begun into his death. The aim of such a review is to look at how local professionals and agencies worked together to safeguard a person who suffered harm and establish whether any lessons can be learned. Recommendations are also made about actions that need to be taken. Published at the end of last week the review reveals a number of failings, miscommunications and lack of action by Northamptonshire’s public services with whom he had had more than 700 contacts in the year prior to his death. 

The review centres on the last 12 months of his life and paints a heartbreaking tale of a man who was trying to get help and to get off the streets. Time and time again during 2019 he complained of his mental health problems to professionals but was seemingly not heard, or at least no effective action was taken. He also voiced fear about sleeping rough and told of how he was beaten up while living on the streets.

Adult social care, mental health professionals, the general hospitals at Kettering and Northampton and the police were all at times found wanting in their safeguarding of Jonathan, who was regularly asking for help.

The 52 page review is punctuated with statements about how Northamptonshire’s statutory agencies acted poorly.

It found ‘opportunities to protect Jonathan were regularly missed’ and ‘there was a lack of purposeful and effective multi-disciplinary working to address Jonathan’s complex needs’.

It continues:

“Not all partner agencies contributed to purposeful and meaningful interventions and there was a distinct lack of concerned curiosity to understand his lived experience and life course”.

It says part of the problem was there was not enough understanding about Jonathan’s situation of multiple exclusion homelessness (MEH). This is where a person is, or has been, homeless and has also experienced either institutional care, substance abuse or activities such as begging or street drinking. It found Jonathan’s situation was seen in isolation, as a housing issue, or a mental health issue, and consequently he fell down the cracks with no one agency taking the lead to secure for him adequate, long term help and support.

Born in East Northants in 1973, things started going wrong for Jonathan - who was known affectionately as Jon Boy - in his mid twenties when he started drinking heavily and using drugs. Police were often called to the family home for domestic incidents and assaults and at 25 he was diagnosed with hypermanic disorder and later as bipolar. After a road accident in 2010 he suffered from spinal injuries and had a stroke in 2017.

His loved ones had tried for many years to help him but he had left the family home in early 2019 after he became violent.

At his packed funeral at Kettering Crematorium last February, his friends and family spoke of how he had a ‘heart of gold’ and just had wanted to find a partner, settle down and have children.

Over the course of his final twelve months he was admitted to hospital forty times. He often took himself, but on two occasions he was taken there by strangers who had found him desperately ill on the street. Sometimes he was taken there by the police.

The report reads as a circular list of hospital admittances, minor treatment and then Jonathan quickly being discharged back onto the streets occasionally with a prescription for analgesia.

He was sometimes recommended for mental health assessment and sometimes they happened and other times they didn’t. Nothing led to him being given mental health treatment or support.

Six months before his death, after a request from a GP, he was assessed by the mental health team from Northamptonshire Healthcare Foundation Trust (NHFT) but the professional did not note acute mental illness or suicidal ideation, which would have led to him being detained. 

The following month he went to St Mary’s Hospital in Kettering (which is run by NHFT) requesting help for his mental health. He was signposted to the emergency department at Kettering General and then the police were called as he would not leave.

At Kettering General, where he was a regular patient, an outdated electronic record on his file dating back to 2010 (that should have been removed) often prevented staff from requesting a mental health assessment. It said one should not be requested unless there was a ‘significant’ change in his mental health.

When he was assessed by the mental health team in September the team found his needs were ‘social’ not due to a mental illness and he was discharged once again. He was assessed again the following month after police took him to the hospital and was once again found not to have acute mental health needs.

He had similar problems when trying to access housing. During 2019 he dealt with various housing departments including Northampton, Wellingborough and East Northants. Throughout January he slept rough, often turning up at hospital emergency departments and between late January and April he was in Nottingham, including a three week stay at the city’s hospital. On discharge the hospital had referred him to a hostel and set in place plans to move into a care and reablement centre. However the move did not happen as in late April he was arrested and brought back to Northamptonshire for a court appearance (in January he had damaged a police vehicle - he told police that he had wanted to get arrested ‘as he was cold and homeless’).

Between May and the end of June he was imprisoned in HMP Woodhill in Milton Keynes. On release from jail he was referred to Wellingborough council’s housing service, but went to Northampton instead without any paperwork. He went to the night shelter in Rushden but was turned away due to previous disruptive behaviour. Housing decided he did not have a priority need and so he slept rough throughout July. That month a housing officer also made a referral for him to a number of supported housing providers but this did not happen.

At the end of the month he was provided with temporary accommodation at the High View Hotel in Wellingborough. He stayed there throughout much of August but then a decision was made to end his accommodation on the grounds of his unreasonable behaviour. Housing also told adult social care  they didn’t believe he had the mental capacity to make a homeless application.

Throughout September and October he slept on the streets, attending hospital periodically until he was taken to the intensive care unit where he stayed for ten weeks.

He was also let down by adult social care. A number of agencies referred him to the service, but on a few occasions his case was closed without any further action taken. The report also notes ‘discord’ between housing and social services about what support he needed and what he was capable of.

It is clear the agencies were not joined up and no one took definitive action to effectively help Jonathan.

There was only one partnership meeting in September 2019 and the review says it lacked structure and a meaningful action plan and that undue confidence was placed on Jonathan’s ability to make decisions.

Tim Bishop chair of the Northamptonshire Adult Safeguarding Board, which commissioned the review, said:

“Whilst there were examples of positive practice, including many examples of determined efforts to help Jonathan, overall the review found that opportunities to protect Jonathan were missed, often due to a lack of planning, communication and coordination between agencies causing Jonathan’s repeated pattern of crises to be rarely acknowledged or understood.

“The review has identified eleven recommendations which aim to act as a catalyst for change so improvements can be made to reduce the likelihood of this happening again and the Board will continue to review and monitor these to ensure the agreed actions are implemented.

“On behalf of Northamptonshire Safeguarding Adults Board, I would like to offer our sincere condolences to Jonathan’s family. They were clear in their wish to see local agencies learn lessons from their tragic loss, to better safeguard adults in Northamptonshire in the future.”

The recommendations

The review has made a number of recommendations which should be actioned by October this year. If enacted correctly they should ensure that no Northamptonshire person who is homeless will be treated as Jonathan was.

The recommendations include housing officers reviewing how they assess priority need; developing a joint protocol between adult social care and housing services about how they support homeless people referred to them; a review of management oversight of adult social care safeguarding alerts and there must be a joint review of how health and social care coordinate and communicate when a homeless person is discharged from hospital.

All agencies must also receive training in multiple exclusion homelessness.

What the public bodies have to say

Both hospitals says changes have and will continue to be made.

Kettering General Hospital’s Director of Nursing and Quality, Leanne Hackshall, said: “Jonathan visited our hospital on multiple occasions in the last year of his life and he was treated in A&E and as an inpatient.

“While his healthcare and nursing assessments were appropriate, it is clear that more could have been done to raise concerns about his overall welfare and co-ordinate more closely with the other agencies involved in that. 

"As a Trust we already have a frequent attender meeting between our A&E clinicians and the mental health team to evaluate patients who frequently attend the department. As a result of this review we plan to seek wider attendance of that group from other services such as housing, homelessness, addiction, and any other disciplines which may be required in individual cases.

“This will help strengthen understanding and joint working and enable better co-ordinated care between the hospital and other agencies and ensure appropriate safeguarding referrals to those agencies where they are needed.

“We are also reviewing our discharge policy and procedures in consideration of our duties under the Homeless Reduction Act (2017) and hope that our actions will improve how we work with our partners to support patients with complex needs and those with multiple exclusion homelessness.” 

Northampton General Hospital Executive Director for Safeguarding Sheran Oke said: “Jonathan visited our hospital on multiple occasions in the last year of his life and he was assessed in A&E and treated as an inpatient.

“His treatment while he was in our care was appropriate, but it is clear a wider perspective was needed to ensure that his care and support needs were taken into consideration.  As an acute hospital we continue to work closely with our colleagues in mental health, substance misuse, housing and adult social care to ensure that patients with complex needs receive a thorough assessment of their needs.

“Our discharge team now takes the lead in ensuring requirements of the Homelessness Reduction Act (2017) are met and we have introduced an electronic alert system to highlight homeless patients to our safeguarding team to ensure multi-professional discharge meetings are in place.”

Leader of East Northamptonshire Council Steven North, whose housing department dealt with Jonathan, said the authority offered its sincere condolences to his family.

He said: “We have carefully reviewed the findings in this case, and the recommendations made, so that as one of numerous agencies involved, we can be more responsive to issues that an individual is having.

“In response to this case and as part of our preparations for the new North Northants Council, alongside fellow chief housing officers, we are in the process of reviewing our decision making processes regarding priority housing need referrals and have improved our ‘Duty to Refer’ guidance with training due to be rolled out in the new council. The move to a single authority for the north of the county will provide opportunities for much closer working between agencies on complex cases.”

Councillor Ian Morris, cabinet member for adult social care at Northamptonshire County Council said: 

“We accept the findings of the report published by Northamptonshire Adult Safeguarding Board regarding the sad death of ‘Jonathan’ in December 2019 and would also like to take this opportunity to extend our sympathies to his family and friends.

“Although considerable efforts were made to support Jonathan, unfortunately the review found that opportunities were missed. It’s therefore vital that we learn from what happened and work is already underway to address the recommendations outlined in the action plan, and will continue as we move into the new unitary councils in April where housing and adult social care will be in the same directorates.

“This includes continuing to improve communication to ensure information is shared effectively between agencies so that the complex needs associated with multiple exclusion homelessness can be addressed.

“We are also ensuring that in the future, anyone facing challenges in this way will be assessed appropriately to ensure the right care and support is put in place, rather than it being regarded as solely a housing issue. We are making sure that staff feel well equipped to work with individuals experiencing homelessness in this way, so that they are able to ask the right questions and exercise their professional judgement.

“It’s clear that dealing with multiple exclusion homelessness is both challenging and complex. Therefore, we are also working together with other agencies to look at the wider issue, and find new ways of tackling these challenges and working differently to achieve better outcomes for any individuals facing this issue now and in the future.”

Rose Lovelock, Assistant Director of Safeguarding and Quality at Northamptonshire Healthcare NHS Foundation Trust said: “We welcome the publication of this safeguarding adult review. Quality patient care is at the heart of everything we do at NHFT, we have actively contributed to the review process to ensure lessons are learnt across the health and care system. While there were no specific recommendations from the review in relation to the care provided by NHFT, we are committed to continuing to work with partners to learn the lessons of this case.”

A Police spokesman said: “Northamptonshire Police notes the very extensive findings around the  involvement of those agencies in this tragic case and we will take away  any appropriate learning from them to inform our practices and procedures going forward.”

Jonathan was one of 778 people in England and Wales whose death was attributable to homelessness in 2019. At 46 he was exactly the average age of men who die after living rough - almost 30 years before the average man.