Diane Margaret Austin-Martin · Prevention of Future Deaths report

On 23rd March 2021 I commenced an investigation into the death of Diane Austin-Martin. The investigation concluded on the 29th July 2022 and the conclusion was one of Narrative: Died from natural causes contributed to by neglect. The medical cause of death was 1a) General debility from multiple sclerosis exacerbated by urinary tract infection, pressure ulcerations and low body mass index

Diane Margaret Austin-Martin was a vulnerable adult with significant health issues including multiple sclerosis. She had significant care needs. She moved to Stockport. The Social Services team in Northern Ireland who had been working with her did not notify Stockport Metropolitan Borough Council of the move or seek to make robust enquiries to ensure the private care in Stockport would be appropriate. She was therefore not visible to Stockport Social Services. A claim was made and accepted by the Department for Work and Pensions for care support for her. Regular payments commenced. There was no evidence of any quality assurance in relation to the care provided. She was seen once by the GP. An attempt to refer to secondary care was unsuccessful and she was never seen or assessed by Multiple Sclerosis Services. Her carers were the people she lived with. The level of care was wholly inadequate to meet her needs. On 22nd March 2021 when police attended the address she was found to have multiple pressure ulcers and be severely underweight. She was found in filthy, squalid living conditions.

1. The inquest heard evidence that there was no clear mechanism to ensure that Social Services were aware of her move despite her vulnerability having being identified whilst she resided in Northern Ireland. As a consequence Social Services were unsighted as to her being resident in Stockport;

2. DWP were aware of her presence and payments were made recognising her needs but there was no mechanism to ensure that the care provided was of an appropriate quality;

3. The inquest heard that where a private care arrangement exists as in this case there is no mechanism to ensure that the care is of a sufficient and appropriate quality in contrast to a resident of a care home;

4. After her initial claim for payment and her initial GP visit she dropped out of sight of agencies until she was found.