The death of a nursing home resident who refused treatment for maggot-infested wounds has prompted a review of the way in which vulnerable adults are safeguarded.

The 64-year-old from west Kent, referred to in the anonymised report as ‘Adult A’, was a recovering alcoholic who had a form of dementia called Korsakoff syndrome.

Other health problems included a brain injury, vascular disorder, epilepsy, diabetes and ulcers and cellulitis on his legs.

The father-of-five died in July last year as a result of sepsis, infections to his legs, diabetes and cirrhosis – after months of refusing treatment which could have helped him.

This week, the East Sussex Safeguarding Adults Board (ESSAB) published the findings of its review into the multi-agency responses to his death, which included recommendations for more joined up approach to protect people with mental health issues.

Following his admission to Maidstone Hospital in August 2015, Mr A had been put in a private nursing home in East Sussex by the South East Commissioning Support Unit Placement Team, on behalf of the NHS West Kent Clinical Commissioning Group (CCG), the body in charge of his care.

“The review demonstrates how crucial it is for all agencies to work closer together, sharing expertise to plan and deliver the best possible services to meet people’s care and support needs" - chairman of the safeguarding board

The report found there had been an absence of knowledge around safeguarding and legal matters on the part of the commissioners and nursing home provider.

At most points at which his mental capacity was assessed, Mr A was found to lack the ability to make decisions relating to his living situation, care and treatment. Paradoxically, his refusal of care and treatment on a daily basis in the nursing home was respected by staff.

The report concluded he had been placed in a facility unsuitable for his complex needs, something which was compounded by a lack of pro-active follow up by NHS West Kent CCG.

Graham Bartlett, independent chairman of ESSAB, said: “While no one factor influenced the outcome of this sad case, the way the different organisations involved interacted with each other is significant.

“The review demonstrates how crucial it is for all agencies to work closer together, sharing expertise to plan and deliver the best possible services to meet people’s care and support needs.”

The report identifies 23 recommendations to try and avoid similar cases occurring in the future.

NHS West Kent CCG and NEL CSU, which took over the South East Commissioning Support Unit Placement Team have since apologised for any shortcomings in Mr A’s care.

They issued a joint statement, which said: “This was a complex and unusual case and we are grateful to East Sussex Safeguarding Adults Board for carrying out a thorough review, which has highlighted a number of important learning points for agencies involved in caring for vulnerable adults with special needs.”

A list of changes have been announced since Mr A’s death, including closer monitoring of patients placed out of area, extensive training for staff in the application of the Mental Capacity Act and the search for further specialist facilities for complex care needs within Kent.