A “vulnerable” man who was supposed to be under constant supervision died after escaping from a mental health clinic, where his carer reportedly neglected to watch him and instead sat looking at her phone.
A coroner has issued a warning following the death of Sydney Piper, 69, who was found dead in a tent in Epping Forest last March a month after he went missing.
Mr Piper had spent much of his life in supported accommodation, due to mental health problems.
As a vulnerable adult with paranoid schizophrenia and a “cognitive deficit” that caused him memory loss, he was supposed to receive constant one-to-one supervision when he left his home.
On February 23 last year, he attended an appointment at a mental health clinic, accompanied by a support worker.
The carer was reportedly aware she was supposed to supervise him when he went outside for a cigarette.
But due to what the coroner described as “significant and sustained lapse in supervision”, he was able to leave alone on three occasions to smoke.
On the final occasion, at 11.14am, he did not return.
A council probe later revealed he had a history of absconding. He had escaped from care homes on three previous occasions, to visit Epping Forest.
It took 37 minutes for Mr Piper’s disappearance on February 23 to be finally noted, at 11.51am.
There was then a further delay of one hour and 23 minutes, before a call was made to 999.
The Met police launched a missing persons investigation, which was hindered the fact Mr Piper had no bank card or mobile phone through which to trace him.
It was not until a month later that he was tragically discovered dead in a tent in Epping Forest, on March 24.
He had been dead for some time. His cause of death was later found to be morphine toxicity. His death was deemed “unexplained but not suspicious”.
Following an inquest, coroner Graeme Irvine has issued a Prevention of Future Deaths report, raising concerns about the supervision Mr Piper received from his carer.
“Upon arrival at the clinic, Mr Piper was ignored by his carer who sat in an area away from Mr Piper and looked at her phone,” wrote Mr Irvine.
“For much of this period, Mr Piper was out of the direct line of sight of his carer.
“The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs.
“The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.
“I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.”
Regarding the two-hour delay between Mr Piper’s disappearance and police being notified, Mr Irvine said: “Procedures indicated by Mr Piper’s care provider were not effectively followed.”
Mr Irvine has also called on better policing and monitoring of homeless encampments in the Epping Forest area. He said Mr Piper’s death was the latest in a number of deaths involving homeless people dying in tents there.
Mr Piper had lived at Waterside Lodge Recovery Centre in Leytonstone since 2018. The centre was run by Outlook Care Ltd, and his place was commissioned by Northeast London Foundation Trust (NELFT).
Staff described him in a posthumous council review as “polite” and “friendly”, though they said he spoke little, suffering from muffled speech that made communication difficult for him.
He liked soft drinks, listening to music, and trips to the barbers and shops. His friends said he enjoyed spending time in the outdoors.
Mr Piper lost his father when he was just 11, before losing his mother in his 30s.
He suffered a “vicious” street attack at the age of just 19, following which he made two suicide attempts.
Council report also finds slew of failings
A review carried out by Waltham Forest Council’s Safeguarding Adults Board following Mr Piper’s death also identified a string of issues.
It said the care worker supervising Mr Piper on February 23 claimed he had been in her line of sight while he was smoking outside. But the report said: “Those who had watched the CCTV footage, including the police, did not agree that he stayed within her line of sight.”
The report said the delay in reporting Mr Piper missing meant “valuable time was lost” in finding him.
“Safeguarding concerns were not raised in good time,” it added. “This was due to communications failures.”It made a string of recommendations, including that adult care providers “should develop a clear protocol and toolkit for rapid response”, setting out clearly what should happen when a vulnerable person goes missing, including how quickly police should be notified.
It also suggested that carers should be reminded by care homes every time they are escorting someone who is at risk of absconding.
A Care Quality Commission (CQC) spokesperson said the health and social care service watchdog is aware of Mr Piper’s death, adding: “We will be reviewing the coroner’s report to determine if there’s any regulatory action we need to take.”
Piotr Rejek, chief executive of Outlook Care Ltd, told the Standard the company will respond to the report by the coroner’s May 10 deadline.
He added: “We have implemented an action plan to understand the outcome of this very tragic and sad incident.
“We're implementing an action plan in partnership with all stakeholders, and that response will be submitted to the coroner.”
NELFT has not responded to the Standard’s request for comment.
