18-year-old who died of accidental overdose was failed by Bedford and Central Bedfordshire authorities

A report into the death of a vulnerable young man found that he was failed by the organisations responsible for his care.

And a cohesive, multi-disciplinary plan for his transition from children to adult services, was not in place despite the “very clear” risks, the report said.

“Max”, 18, was found dead after an accidental overdose in his flat on May 22, 2020.

Bedford Borough Council and Central Bedfordshire Council both said they were “deeply saddened” by Max’s death – and would take on board the recommendations made in the report.

Bedford Borough and Central Bedfordshire Safeguarding Adult Board (SAB) commissioned a Safeguarding Adult Review (SAR), which was published on Tuesday (October 11).

A SAR aims to establish if there are lessons to be learned, to review procedures, and to develop best practice – rather than re-investigate or apportion blame.

The report’s author, Sarah Williams, an independent safeguarding consultant, met with Max’s family as part of the review.

She wrote that while the parents expressed their gratitude to the many individuals who supported Max, they spoke of a “lack of coordination” in efforts to keep Max safe.

Max’s father described the escalation in harm as “watching a train crash happening in slow motion”.

Max had wanted to live in his own flat and he moved into a private one-bed flat in Bedford in January 2020.

This was after his parents co-signed the tenancy and on the basis that Central Bedfordshire Council (CBC) managed his Personal Independence Payments to support him with his finances.

The council’s Preparing for Adulthood team said that as Max had moved to Bedford Borough and had not been placed by CBC, he was now the responsibility of Bedford Borough Council’s (BBC) mental health services and adult social care.

The report said Max was “wholly unprepared” to live alone and that his mental capacity to make decisions around weighing up risk had not been adequately assessed.

And there wasn’t a care plan or safeguarding plan in place from adult mental health or social care to support Max.

He started to use drugs which escalated “extraordinarily quickly”, which the report said was likely aggravated by his poor impulse control and self-medication to manage the unboundaried situation he found himself in.

During periods of crisis he was admitted to mental health wards, but was released because he was not detainable for treatment under the Mental Health Act 1983.

A clinician, who worked with Max as both an adolescent and after he turned 18, said in her view, his mental health had not deteriorated, rather, “these crises related to his unmet care needs”.

The report said during the last weeks of Max’s life, practitioners and his family made strenuous efforts to protect him, desperately trying to put measures in place to mitigate the escalating risk in chaotic circumstances and under the strictures of the Covid-19 lockdown.

However, delays in coordinating the multi-agency response meant that these efforts were fragmented and lacked leadership, it added.

The report said cohesive, multi-disciplinary planning should have taken place to ensure that mental health, safeguarding, care and accommodation planning was coordinated for Max.

This should have been well in advance of his transition to adult services given the very clear risks and the likely difficulties in commissioning a suitable placement.

The report made 12 recommendations, including better inter-agency procedures for the resolution and escalation of cases with delays or when there are disagreements between agencies.

It was also recommended that an accommodation pathway should be in place to ensure young people and young adults already at risk are not placed at greater risk by being placed in unsuitable housing.

A joint statement from Central Bedfordshire Council’s director of children’s services, Sarah-Jane Smedmor, and director of social care, health and housing, Julie Ogley said: “We are deeply saddened that Max’s life ended the way it did, and we extend our sincere condolences to Max’s family and to everyone who knew Max.

“Max left a lasting impression on many colleagues at the council and was supported by our Children’s Services throughout Max’s childhood.

“We accept the recommendations made in the report and will ensure that the identified learning is acted upon.

“We will continue to work closely with all partner agencies to improve the service provided to young adults.”

A Bedford Borough Council Statement said: “We are deeply saddened that Max’s life ended the way it did, and our sincere condolences go to Max’s family and all that knew Max well.

“The review clearly shows partner agencies need to be working closer together to provide a more joined up service for our young adults.

The board will now take all recommendations made in the report forward, ensuring that the identified learnings are addressed across the system.

“Work has already progressed in these regards and will continue to be monitored through the board and within the organisations concerned.”

Sarah Williams said she was grateful to the practitioners for sharing their insight so honestly during her review.

She said the efforts they made to support him and try to keep him safe were very clearly apparent throughout the review process.