When news happens, text SDE and your photos or videos to 80360. Or contact us by email and phone.
Still no apology after failures led to death of Jonathan Ray
IT was a death that shocked the community and turned the spotlight on to the care of some of the most vulnerable people in our society.
Jonathan Ray suffered from a learning disability, epilepsy and scoliosis and was supposed to be looked after in his 24-hour supported home.
But the 49-year-old’s underweight body was discovered in appalling squalor in his own faeces and urine.
It sparked anger and a widespread Serious Case Review of social care.
Today the Daily Echo can reveal the full and disturbing details of the Review’s report into the “preventable” death of Mr Ray.
And it goes on to list 63 care recommendations to ensure a similar tragedy never happens again.
We can also reveal that nearly two years after his death his family are still waiting for a personal apology from Wessex Regional Care – the firm entrusted to care for him – and the city council which commissioned Wessex’s services.
His brother Nicholas Ray said: “I am of course glad that safeguards and recommendations have been put in place which should mean my little brother’s life was not taken in vain and that another vulnerable adult could be saved from his same fate.
“But this does not change the fact there was a distinct lack of care that led to my brother’s death. The way he was treated by those who were supposed to be caring for him was disgraceful.
“The fact is he died through neglect and no matter what they say now it will never bring my brother back.
“It’s nearly two years since he has died and still I have had no apology, nothing at all from the council or Wessex. There have been no calls, no letters, nothing. It is disgusting.”
The Daily Echo can also reveal today that:
- Southampton City Council still has vulnerable people in the care of Wessex Regional Care – and it vows to continue to use the care provider.
- Wessex Regional Care maintain they have reviewed their proceduresyet still declined to answer some key questions put by this newspaper.
- Three members of staff from Wessex Regional Care were referred to the Independent Safeguarding Authority – but no action was taken and it is believed nobody has been disciplined over the tragedy.
The Serious Case Review, ordered following Mr Ray’s inquest which branded his death “preventable and unnecessary”, says actions were not “malicious or deliberate” but highlights a “group of contributory factors” which allowed the part-time Sainsbury’s worker to die.
Among the Review’s findings – contained in the 81-page report – are details of Mr Ray’s harrowing last hours at the flats in Harefield Road, Southampton .
The poor level of cleanliness and hygiene in his flat and the effect this had on the diarrhoea he suffered for five weeks, leading to his death from dehydration, colitis and epilepsy, went “largely unnoticed.”
The report says Mr Ray never had the care hours he was promised and adds a support worker at Wessex Regional Care missed a “pivotal opportunity” when he failed to return to check on him for thirteen hours because he was tired – despite last seeing him in a soiled state and unable to stand.
The Review report also says the care organisation had “too few experienced care workers and duty managers to cover an urgent situation” and had “inadequate policies or protocols” saying Mr Ray’s real needs and anxieties were not addressed.
The council, which commissioned Wessex Regional Care, was additionally criticised for failing to monitor Mr Ray’s care and said the deficiencies at the flats “should have been known”.
The council’s Learning Disability Team did not visit the flats very often – only if a complaint had been received, it reveals.
“Several violent and unpleasant serious incidents” were reported at the flats painting a picture of the deteriorating conditions Mr Ray faced in his final months, yet troublesome residents could not be evicted due to “elementary mistakes” like quoting the wrong dates.
Police were called more than 50 times in 2010 alone and 20 times in the month before Mr Ray’s death, the report states.
But the main problem was communication between staff and different agencies because, despite many people involved in his care, everyone made assumptions he was being adequately looked after.
The report’s damning conclusion pinpoints a “systemic” cause before highlighting a list of recommendations, which include a complete overhaul in the council’s monitoring arrangements, retraining, making sure the police now alert authorities when they are called to incidents involving vulnerable people and informing close relatives when a service user is ill.
- Jonathan was left soiled and bleeding on sofa
- Recommendations must be implemented
- Key questions that still need to be answered
- Council will still use care firm
The report concludes: “Had all care staff been aware of all the facts of his illness and the advice of the GP to ring the duty doctor and had used their own observation of Mr Ray being unable to walk or get out of bed to summon an ambulance, appropriate action would have followed.”
It adds: “The cause of Mr Ray’s death was systemic. A group of contributory factors combined to create a situation where a vulnerable adult was allowed to die in circumstances where he was living in supported accommodation.”
The Southampton Safeguarding Adults Board, which commissioned the Serious Case Review, told the Daily Echo they are “committed” to learning lessons from the review and will make sure action is taken to ensure a tragedy does not happen again.
In a statement the Board says initial reviews of the situation were completed by agencies immediately after Mr Ray’s death. It goes on: “They have disseminated the learning from these, addressed all the learning points that were identified and provided evidence to demonstrate how learning has been embedded within practice to the Southampton Safeguarding Adults Board.
The statement adds individual agencies concerned with Mr Ray’s care are now revisiting their action plans in light of the Serious Case Review Panel’s findings, and the Safeguarding Board will monitor future progress.