Hadley John Savory · Prevention of Future Deaths report

Hadley John Savory was found dead at his home address in Margate on 13 December 2019. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 11 August 2021. My conclusion was that his death was drug related, in addition, a short narrative conclusion was given as explained further under section 4 below.

Hadley John Savory was discharged from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. A multi-agency meeting did not take place prior his discharge from hospital. The plan for Mr Savory’s care, support and treatment in respect of his substance misuse, physical health, mental health and social care needs is unclear.

Mr Savory’s presentation declined in the community. Safeguarding referrals were made but no multi agency meetings were convened pursuant to safeguarding duties under the Care Act or as per the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour.

Police made entry into Mr Savory’s home address on 13 December 2019, he was found to be deceased. Toxicological evidence indicated that Mr Savory had taken a lethal dose of methadone. There was no evidence that Mr Savory had intended to take an overdose.

(1) There was no evidence of a multi Agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs;
(2) There was no recording (or available evidence of recording) of attempts to escalate internal disagreements as to which team Mr Savory should have been allocated to. Nor did the evidence establish how internal disagreements as to allocation of cases were recorded;
(3) The evidence was not clear as to how eligible care needs under the Care Act are met when a service user is transferring between services. In Mr Savory’s case he was assessed as having eligible needs but no care and support plan was developed;
(4) The evidence demonstrated that there was a lack of clarity as to the interrelationship between safeguarding duties under the Care Act and the operation of the Kent and Medway Multi-Agency Policy and Procedures to Support People that Self-Neglect or Demonstrate Hoarding Behaviour;
(5) It was unclear as to how information sharing operated in respect of service users who are identified as potentially having fluctuating mental capacity in respect of their care and support needs.