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Further Information

Important learning from review of homeless man's death

Northamptonshire Safeguarding Adults Board have just published a Safeguarding Adults Review (SAR) in respect of Jonathan.

This SAR was commissioned following the death of Jonathan Upex in December 2019. Johnathan was a 46-year-old white British male who was living in a Wellingborough hotel at the time of his death. Jonathan had care and support needs and experienced abuse and neglect, including self-neglect. There were also concerns about how agencies worked together to safeguard Jonathan. 

Jonathan was considered to have multiple vulnerabilities and risks which were confounded by homelessness, in particular, rough sleeping. He had spent many nights sleeping on the streets, including during the cold winters months, often at freezing temperatures. He had frequent visits to Emergency Departments (EDs) and had a history of offending, including imprisonment. Despite regularly coming to the attention of a number of statutory services as an adult experiencing street homelessness with significant physical and mental health conditions, his priority need for housing together with his care and support needs were not readily acknowledged.

The review found more than 700 case records had been lodged against his name in a year by several agencies, including more than 40 visits to A&E. The review said 

'Opportunities to protect Jonathan were regularly missed, often as a result of professional preconceptions of care and support needs and risk, including a narrow interpretation of policy and the relevant legislative provisions and principles. In their reflective discussions with the Independent Reviewer, several agencies commented on the lack of planning, communication, care planning and coordination between agencies, whereby Jonathan’s repeating pattern of crises were rarely acknowledged.' (1.4 main report)

'Despite the numerous examples of positive practice and the determined efforts to support Jonathan, the evidence has nonetheless led the Overview Report Author to conclude that there was a lack of purposeful and effective multi-disciplinary working to address Jonathan’s complex issues. [...] There was a clear failure to implement a meaningful and personalised plan of action and a failure to assess his social care needs so that these were not merely confined to just a housing issue.' (7.5 main report)

This review presents important learning on:

  • housing and homelessness
  • hospital discharges
  • care assessments and safeguarding
  • inter-agency collaboration, leadership and coordination

Read the executive summary & full report here: Northamptonshire Safeguarding Adults Board Safeguarding Adults Review Jonathan 2020.