Kevin George Morgan · Prevention of Future Deaths report

On 29th July 2016 I commenced an investigation into the death of Kevin George Morgan, aged 53. The investigation concluded at the end of the inquest on 19th May 2017. The conclusion of the inquest was “Open”.

Mr Morgan suffered from insulin controlled type 1 diabetes that was poorly controlled. He was not registered with a GP and had not been in contact with family for several weeks. Family called Police who attended the flat. On looking through the letterbox Mr Morgan could be seen deceased lying on the floor in the hallway. Entry was forced, ambulance attended and death confirmed, there were no suspicious circumstances. His body was heavily decomposed. At the time of his death it was known that he suffered from diabetes, that he had accumulated rent arrears, that his telephone had been disconnected, that he was without gas and electricity, that he was not claiming benefits and he suffered from mental health problems.

(1)That social services and the housing team were aware of the problems experienced by Kevin Morgan and yet there was no effective follow up.
(2) That a safeguarding alert was completed by Kevin Morgan’s Mother and, despite her serious concerns, the response was to arrange a visit where Kevin Morgan refused to engage.
(3) That the case was reviewed by senior managers on at least two occasions and no further action was taken.
(4) The police were never requested to conduct a concern for safety visit despite such a visit being recognised as appropriate.
(5) It was accepted by the Adult Social Care Access Team that a meeting of senior professionals should have been called to consider the case and prepare a plan.
(6) Following the death of Kevin Morgan there was no Serious Incident Review conducted by social services and it was not referred for a safeguarding review so that lessons have not been learned from this incident. Without such a review a similar incident could occur in the future.