A Derbyshire care facility at which a man with behavioural conditions suffered fatal injuries after a fight with another resident was a “high-risk” environment which was “not designed nor able to meet their needs”, an investigation has found.
Details of the incident have been disclosed in an annual report, to be discussed next week, and in a review, both carried out by the Derbyshire Safeguarding Adults Board.
The incident involves the death of Robert Thomas Chaplin, aged 49, on January 23, 2019, after an altercation with a fellow resident at the Morewood Centre in Wingfield Road, Alfreton.
Derbyshire County Council, which runs the Morewood Centre, says that since the incident it has made numerous improvements, including wider training which it feels “will ensure we are better placed to prevent a recurrence”.
Crown Prosecution Service officials ruled the incident was an act of self-defence and an inquest into Mr Chaplin’s death, completed last July, also carried the same conclusion.
The inquest detailed that staff were adequately trained and that there was not evidence indicating that Morewood was “totally unsuitable” for Mr Chaplin or the fellow resident.
Coroner Peter Nieto had said: “Although not ideal, the placement was not inappropriate for either of the men.”
However, a report from the county’s safeguarding board concludes: “The lack of appropriate resources to meet the needs of adults with complex needs was the most significant factor.
“There was an absence of crisis accommodation and specialist services. Adults with complex needs and behaviours that challenged came together in crisis circumstances.
“This created a high-risk dynamic within an environment that was not designed, nor able to meet their needs.”
The review talks about the need for more inter-agency work and that management of potential domestic abuse was missed, as well as missed chances to escalate other signs of concern.
Mr Chaplin, who is referred to as Thomas in the board’s review report, is said to have had a learning disability, an autistic spectrum condition and was diagnosed with bi-polar affective disorder.
It writes: “These complex needs made the world a challenging place for Thomas. He often struggled to communicate his needs and could become highly anxious.
“Thomas used alcohol in a problematic way. This added to his difficulties and his behaviour could be aggressive and challenging for others to cope with.
“Thomas had been supported to try and live independently but unfortunately; these arrangements rapidly broke down and had led to long term hospital admission.
“Thomas was highly reliant on his mother who was a major support in his life. However, Thomas could become angry and physically aggressive toward her.
“Her role as carer became more difficult as she became older and became a carer for other family members.
“Thomas moved to the centre as a short-term crisis admission, following the breakdown of his independent accommodation.
“Health and social care worked together to try and support him and source alternative accommodation, but Thomas remained at the centre for nine months.
“The centre was designed for short breaks for adults with learning disabilities. However, other people with highly complex needs were also admitted to the centre in crisis.
“One such person was, [the person who punched Thomas]. Very sadly, Thomas and [the other resident] became involved in a conflict.
“[The resident] punched Thomas causing him to fall. He sustained an injury from the fall and died soon after.”
Last July’s inquest details that Mr Chaplin had been involved in an argument with two other residents, after which he asked for £30 of his spending money and went to the pub.
After he returned, “clearly drunk”, Mr Chaplin was “more aggressive and confrontational”, exchanging violent and aggressive comments with another resident.
This later led to a further exchange of confrontational comments, following which the resident punched Mr Chaplin in the face, leading to him suffering cardiac arrest before dying at Queen’s Medical Centre due to a hypoxic brain injury.
Helen Coombes, the council’s acting executive director for adult social care, said: “I’d like to express my heartfelt condolences to everyone who knew and loved Robert.
“Derbyshire Safeguarding Adults Board published its report in 2021 and we fully accepted the findings of the review which aligned with our own internal management review. By the time the report was published we’d already put in place an action plan to address the learning points raised and these were fully implemented.
“I also note that the report highlighted many aspects of good practice and partnership working between adult social care and health colleagues and the report author found that the tragic consequences could not have been predicted.
“The report did, however, recognise the very significant issues faced by the staff team in this case in meeting the different needs of people who present with complex and challenging behaviours.
“Over the last 18 months we have addressed this concern in our revised admission protocols, additional training and improved communications both internally and with system partners. We have also established processes to check these actions are working as they should to ensure that we continue to embed the learning from the review.
“We believe that this will ensure we are better placed to prevent a recurrence across all our provision for people with a learning disability and/or who are autistic.”
