Man with complex health and social care needs died at Royal Berkshire Hospital after months of neglectful care

Aubrey, 45, died on June 29, 2017, at Royal Berkshire Hospital, of a stroke, colorectal cancer, sepsis and kidney disease, after a series of communication failures by West Berkshire agencies.

A Safeguarding Adults Review (SAR) found that care provider Bee Friends failed to adequately care for Aubrey, an amputee who suffered from pressure wounds.

Aubrey’s mother said: “I feel Aubrey has been let down by people who should have helped him and cared for him. We knew little of the true struggles he was experiencing.

“Please do not allow any other family or individual to experience this. I saw my son into the world and watched as he took his last breath.

“I feel angry that he was not allowed to slip away the way he would have wanted. He had so much left to do and he and I were not able to do this together.”

The report, by the West of Berkshire Safeguarding Adults Board, found multiple issues with the way the man’s deteriorating health was managed by the care provider and other health agencies.

A lack of collaboration between agencies and communication with his family meant interventions were isolated, which prevented Aubrey’s escalating needs and the full extent of his deteriorating condition from being seen.

Bee Friends failed to communicate about significant issues, such as Aubrey's deteriorating pressure wounds, which would have led to a comprehensive review of Aubrey’s care.

The report states that the care provider was was neglectful in its 'ommission to act'.

Bee Friends was judged inadequate by the Care Quality Commision (CQC) in March 2017. However, the provider failed to notify its patients of its rating.

Adult Social Care's own review raised no concerns regarding the quality of care delivered to him, based on his own happiness with his care, despite historic evidence of self-neglect.

When concerns were identified by Aubrey or his family, a response was never received.

The family do not believe any information or discussion was had with Aubrey relating to care quality concerns and question how Aubrey was able to make an informed choice about remaining with the care provider.

Bee Friends closed in November 2017, after being decommissioned of services to West Berkshire patients three months earlier.

Aubrey’s mother added: “Aubrey was my youngest, my baby boy. He was born with some problems, but we loved and cared for him unconditionally.

“He was a determined, sociable man with such a sense of humour. He would laugh uncontrollably, a real belly laugh, when he found something funny.

“He enjoyed life and lived it to the full. I miss his daily phone calls so much, he would tell me about his day. He was a caring son and worried about me after his dad died.

“On occasions he would phone me to tell me it was 11pm and no one had come to help him. He was determined and would have wanted to sort things out himself.”

A SAR is a multi-agency process that considers whether serious harm experienced by an adult, or group of adults, at risk of abuse or neglect, could have been predicted or prevented.

The report can be viewed here: http://www.sabberkshirewest.co.uk/media/1370/aubrey-sar-report-v30.pdf