Oliver

19th January 2023. I will never forget the day that I heard the news. I could feel something was wrong in the whole of my body. It was like an energy that I can only describe as between euphoria and panic. It’s a bit like when you hear bad news and you laugh, your body just doesn’t know how to respond! I had the message that we couldn’t get hold of Oliver. I didn’t worry at first and thought I bet he’s just annoyed with us for not transferring him any money. As the day went on, I couldn’t settle and thought I’ll get a call soon and as I thought he’s just angry about the money. Never did I think history would be repeating itself. 9 years ago, we couldn’t get hold of my brother who was 37. We left him messages but knew it was very unusual for him not to be in contact with my mum or dad. My mum said she knew he was dead but didn’t want to believe it. The police were called. As my mum and dad stood outside his flat waiting for the police to force open the door, minutes later they received the devastating news that my 37-year-old brother was dead on his sofa. After his body was taken away, we went into his flat and cleared the fridge. We left and I remember my dad saying that’s it then. His life was over forever with no warning. I heard my husband come out of his office and I just knew. I remember saying is he dead and when he nodded his head I just screamed and started running around the house. Anyone that has heard news that is such a shock will know that words can’t fully describe how I felt. I honestly didn’t know if I would be able to live with the pain of losing Oliver. The thought that I would never see him or speak to him again was too painful to bear, it was intolerable and still is. I like all people am no stranger to loss. My cousin died when he was 15 and 9 days from cancer. He was a brave warrior and and an amazing young man who dealt with his illness with courage and dignity. I was with him when he died peacefully at home. I had also lost my Nan whom I was close with whilst my son was in hospital having been born very early and poorly. However, this death felt different. I was angry as I know that had the systems that have been put in place to protect people been followed properly, he would be alive today. The only way myself and his uncle will feel any peace is if we can make those in power listen and make much needed simple changes to protect other vulnerable people. As with many deaths where a Serious Case Review is necessary there were a catalogue of errors that lead to his sudden death. Oliver had been taken to A & E suffering with what his Keyworker said was psychosis. He was admitted and stayed in a side ward at A & E with no windows for a week waiting for a place at a psychiatric hospital for assessment. The local psychiatric hospital had no spaces, so he was sent out of county. We were relieved when he was finally told he would be taken to The Langford centre which is a private hospital. Oliver was visibly relieved too. His uncle was understandably shocked when he received a call to say that there planned to discharge Oliver the next day. We immediately complained and a zoom call was set. At the meeting his family and support workers at his medium support housing placement asked for him to be sectioned repeatedly. This was refused. It was however agreed that on discharge Oliver would require a high level of support. A further zoom call was scheduled that would also include a worked from mental health and the housing department. Oliver joined this call at the end of the discussion and told everybody that if he was discharged, he had a plan to kill himself. Housing were fully aware that on discharge Oliver would require high support accommodation and, on the call, his medium support accommodation terminated his tenancy as they didn’t feel that they could meet his needs. Again, with no warning his uncle received a call telling him that Oliver would be discharged that day. He was sent to a hotel with 3 days of strong medication and no care plan. The following day he was told to go to the housing department. He was told that there was no local accommodation available, and he would be sent to temporary accommodation out of county, but this would only be for 2 nights. However, this sadly wasn’t the case. Oliver would be at this accommodation until his death in January. His uncle had numerous email exchanges with the housing department stating how he needed high support accommodation as they had already agreed to. His GP also supported him needing to be in his hometown. The temporary accommodation that he was sent to have no washing machine and only 1 microwave between 40 vulnerable people. As he had moved out of county, he received a letter discharging him from his mental health services. He was he believed only out of county whilst waiting for accommodation and did not want to be discharged from services that knew him and his needs. Hard drugs were freely available, and we believe it was his feelings of hopelessness and lack of support that led to his death. Another important point to add is that Oliver was a care leaver. Once he turned 25, he lost the support of his PA who had been a constant in his life and a rock to Oliver for a number of years. As it is said care doesn’t end at 18, 21 or 25. As his recent corporate parents I’m outraged that they sent a known vulnerable young person to totally unsuitable and unsafe accommodation. I am now dedicated to campaign to make simple changes to safeguard other vulnerable people. I believe one simple change could safeguard many vulnerable including children. Appointing a lead professional to oversee the cases of a vulnerable person would ensure all agencies communicate and collaborate effectively. Also, the lead professional would take ownership of the case and make sure all records are up to date and acted on. Agencies working with vulnerable people to have training on unconscious bias and how each vulnerable person has a story that they know nothing about. It is easy to become desensitised and forget what challenges vulnerable people have faced and are still facing. Training should focus on a shift from they didn’t engage to how can we enable them to engage with services. Language that is used by agencies to change and be up to date. For example, sex worker to be labelled exploited for sex and care leavers to care experienced. Temporary accommodation should have basic standards such as a cooking facility and access to a washing machine on site. Care leavers to have access to support services and transitioned to adult social care if needed. As I have said, care doesn’t end at 18, 21 or 25.