A 39-year-old man from Brighton and Hove died from a drug overdose after he was arrested having been falsely accused of rape.
The man was a former rough sleeper who had just moved back to temporary housing in Brighton from Kendal Court, in Newhaven.
An official review found that the woman who made the rape allegation to police had been financially exploiting the man, who had learning disabilities.
The review, which called him Christopher, said: “It was apparent from the investigation that there had been consensual intercourse at the time of the alleged offence and furthermore both the victim and Christopher had used substances and were not compos mentis.”
Professionals had “concerns about whether Christopher was able to have safe relationships and recognised sexual boundaries in relationships”.
But this “was never addressed” and “his poor understanding around sexual boundaries when combined with substance misuse also meant he was vulnerable to exploitation”.
He had previously been raped himself.
Shortly after his arrest, Christopher’s mental health was reported to be in “free fall” and he turned to drink and drugs to cope, leading rapidly to his death.
Two years before he died, while he was staying with the YMCA, hostel bosses “reported to the police that Christopher was being harassed at his place of residence and was being targeted for his benefits money by another resident at the YMCA accommodation.
“The same person was said to be ‘pushing heroin on Christopher’ and helping him to inject.
“All the residents involved were too scared to talk to the police. The suspect was arrested but there was insufficient evidence to prosecute.”
Christopher had also suffered childhood trauma, the review said, and lived a chaotic life, with spells as a rough sleeper.
The review – a “safeguarding adults review” commissioned by the Brighton and Hove Safeguarding Adults Board – added: “While professionals provided significant levels of support for Christopher and much time was spent on assisting him with services, there was limited evidence of professionals considering or undertaking safeguarding duties under the Care Act 2014.
“There were no formal inquiries or assessments made by any agency that were formally defined as safeguarding.
“There were also no multi-agency meetings or strategy discussions held during this time.
“This was despite 13 (alerts) being passed by the police to professionals in the local authority (Brighton and Hove City Council) which related to incidents of violence against, or exploitation of, Christopher.
“During the review period the police created 116 incident logs relating to Christopher. From these there were 20 crimes recorded where he was recorded as the victim and five where he was recorded as the suspect.”
The review noted the lack of appropriate joined up help – and the Safeguarding Adults Board said that it had asked for the review because Christopher “died as a result of abuse or neglect”.
The board said that “partner agencies could have worked together more effectively to protect” Christopher.
And, it said, this was “despite evidence of self-neglect and questions about Christopher’s capacity to care for himself and make safe decisions”.
The board added: “The report concludes that significant support was provided by a range of agencies during this period – and lack of resources was not obviously the reason for non-intervention by professionals.
“Rather (non-intervention resulted from) assumptions made about his capacity to make safe decisions and a reluctance to intervene or to challenge Christopher’s view of the world.
“This SAR (safeguarding adults review) has examined practice from some time ago and it is reported that there have been significant improvements in terms of training and changes in service delivery.
“The challenge is to be confident that this input has resulted in changes in practice and better outcomes for service users.”
It is the third review along similar lines in five years, with key professionals appearing not to pick up on the safeguarding needs identified by frontline workers from other organisations.
In Christopher’s case, despite living with learning disabilities, he often sounded more capable than he was.
But weeks before he died, one professional realised “that he had very limited life skills, finding it difficult to prepare a basic lunch of a sandwich”.
The report also said: “Christopher was displaying a number of symptoms typical of someone who had or was experiencing trauma.
“There was evidence throughout the review that past events were being re-triggered and that Christopher was feeling judged or blamed for his repeated contact with services.
“The significance of these repeat trauma experiences was not fully understood in terms of the gravity of impact that this had on his mental and physical wellbeing and safety.
“Agencies constantly sought to find out ‘What was wrong with Christopher’ rather than ‘What happened to Christopher’.
“The mental health assessment said that Christopher was responding to social circumstances not suffering from a long-term mental illness.
“This assessment, in common with others, did not identify his problems (homelessness, substance misuse, self-neglect and self-harm) as possible responses to past trauma.”
The report also said: “One aspect that was missing from the support for Christopher was a proactive support service that was able to provide him assistance immediately even if he moved.
“All too often, by the time the assessments were in place, he had moved address and the process had to restart – or it was felt that it was inappropriate to start a service while he was unsettled.
“This unfortunately meant that he was slow to receive necessary support and led to a deterioration in his wellbeing.”
The review added a warning: “If there remains a response that says people cannot receive these supports until they are settled, then it is probable that individuals such as Christopher will not receive the therapeutic interventions that they need.”
Christopher died in March 2017.
While the “safeguarding adults review” identified improved knowledge and practice, it also made recommendations aimed at providing better care for the most vulnerable, and sometimes most challenging, people who live among us.
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