The families of two men who were seriously injured while living at a Horsham care home were let down by a string of failures, according to a new report.
Gary Lewis and Matthew Bates were both residents at Beech Lodge care home in Guildford Road, Horsham, when they both suffered broken legs in separate incidents within hours of each other.
The home is run by Sussex Health Care, which also runs a string of other care homes in the county, nine of which are currently at the centre of a police investigation following the deaths of 12 people.
In a Safeguarding Adult Review this week into Matthew’s and Gary’s injuries, it was stated that there were delays in notifying the police after Matthew and Gary - both of whom have cerebral palsy and neither has been able to walk or talk since birth - were treated at East Surrey Hospital for their injuries.
And that was despite concerns from an emergency department consultant who issued a safeguarding alert and documented his concerns stating: “I do not think these fractures would have occurred spontaneously and DO have concerns that they MAY have been sustained as a result of a non-accidental injury.”
The injuries happened in 2015 and Gary’s brother Martyn and Matthew’s father Mark have been battling ever since for answers to what happened - and this week they have vowed to still not give up.
They have enlisted the help of former Met Police detective Clive Driscoll, who led the investigation into the Stephen Lawrence murder.
The Safeguarding Adult Review has made 19 recommendations, 14 of them for the West Sussex Safeguarding Adults Board.
The review, undertaken by Brian Boxall, a retired Detective Superintendent who served with Surrey Police for 30 years, said that exclusion of the men’s two families from an initial meeting concerning the men’s injuries ‘fuelled the families’ suspicion that there was possible collusion to hide the truth.”
He said that there was confusion over an initial inquiry and this resulted in an “ultimate conclusion that the time and reasons for the injuries could not be identified, and assumptions made that they had occured due to moving and handling errors.”
West Sussex Safequarding Adults Board chairman Annie Callanan said both Matthew’s and Gary’s families had “expressed concerns about how agencies have responded to the injuries. Despite the high level of contact they have had with a number of agencies, both families believe that agencies have not been honest and open with them.”
She also said the report made connections with a review following 19 deaths in the Orchid View care scandal in Copthorne.“The safeguarding adults board takes note of those connections,” she said.
A spokesperson for Sussex Health Care said: “The report identifies a number of shortcomings by the public agencies involved in the safeguarding roles for these two vulnerable people.
“We sincerely apologise to the two vulnerable people and to their families for the distress caused by these circumstances. We are committed to working with partner agencies to improve standards in all of these areas.
“The report makes a total of 19 recommendations to ensure that all parties involved have learned from this case and have put in place measures to minimise the risk of any similar recurrence.
“The first recommendation specifically cites four steps that Sussex Health Care should take, and we can confirm that they have all been implemented.
“1. We have appointed a new Head of Safeguarding, who is a former police officer with many years of experience; a new Director of Quality, Compliance and Service Improvement, also with decades of experience in providing high quality care; and have set up a dedicated Quality Team to work alongside our Operations to offer appropriate oversight and challenge.
“2. No agency staff are permitted to work at any of our services unless they have a staff profile in place that clearly identifies them and ensures they have the right qualifications and experience for the role they are fulfilling.
“3. Dedicated care plans for residents with osteoporosis, clearly identifying the condition and with clear manual-handling instructions, have been in place for all residents with this condition since immediately after these incidents happened.
“4. In addition to the range of personalised communications methods in place to meet individual needs, we have also adopted the National Early Warnings Score system, which acts as a further early indicator if anyone is in pain or feeling unwell.
“The health, wellbeing and safety of the people we support is our top priority and we are absolutely committed to providing the highest quality care.
“Beech Lodge has been regularly inspected by the CQC since the events of 2015. The most recent inspection report, published in November 2017, rates the home as ‘Good’.”
Amanda Jupp, West Sussex County Council cabinet member for adults and health said: “It’s difficult to comprehend the pain and upset caused to the two vulnerable individuals involved and their families and loved ones in this case.
“It is clear from the report that the care provided by Sussex Health Care was not good enough. West Sussex County Council take on board the recommendations for the council that arise from the independent report and will continue to improve our safeguarding services. We will work closely with the Independent Safeguarding Adults Board to oversee the safety and care of residents in all West Sussex-based care homes.”