Families 'failed' over West Sussex care home fractures
The families of two men whose legs were found to be fractured at a care home on the same day were "let down" by the ensuing inquiry, a report has said.
The Safeguarding Adult Review said Matthew Bates and Gary Lewis, were probably poorly-handled at Beech Lodge in Horsham, run by Sussex Health Care.
It made 19 recommendations - 14 for the West Sussex safeguarding adults board.
Sussex Health Care has apologised to the men. The board said it would implement the recommendations.
The report said the major lesson to be learned was the impact on the men, the families and the agencies of the "failure to undertake a co-ordinated evidence-led safeguarding and or criminal inquiry".
Martyn Lewis, brother of Mr Lewis, said families were "dismissed" and the agencies refused to answer questions.
The families enlisted the help of former Met Police detective Clive Driscoll, who led the investigation that saw two of Stephen Lawrence's killers convicted of murder.
Mr Lewis said: "We made complaints that never got upheld. We had to use the system to get answers.
"They have not been open. They have been very opaque.
"When you're seeking answers, you ask questions. And if you don't get answers you keep asking questions - their solicitors have called me vexatious and obsessive."
He said both families still needed to digest the contents of the review with advisers.
The report found that when the two men - described as having learning difficulties, cerebral palsy and osteoporosis - reached hospital on 1 April 2015, concerns were immediately identified and discussed with safeguarding staff.
It said safeguarding alert forms were completed later which stated the police were aware, but the report continued: "It has now been established that the police had not been informed on the day by any agency and did not become aware of the incidents until 9 April."
Report author Brian Boxall, a retired Surrey Police detective superintendent, said: "At an early stage handling and moving was the emerging explanation, and this was never strongly challenged."
He said a failure to investigate the injuries in a "thorough and timely manner" had led to a confused inquiry and an uncertain conclusion which let the men and the families down.
Mr Boxall said the lack of answers led the families to believe there had been collusion between agencies to suppress the truth, but added: "The author has been presented with no evidence that indicates collusion to influence the safeguarding enquiry."
Of the 19 recommendations, 14 were for the West Sussex safeguarding team, with the remainder for police and councils.
The recommendation to police was the force should ensure it undertake or lead investigations to ensure evidence-gathering was not missed or compromised.
Annie Callanan, independent chairwoman of the West Sussex safeguarding adults board, said it was important to keep those most affected - the men and their families - at the forefront of the review.
Orchid View 'connection'
She said Mr Boxall had spoken to and worked with the men with the support of family members, but families still had concerns about the agencies involved.
Ms Callanan also said the report made connections with a review following 19 deaths in the Orchid View care scandal in Crawley.
"The safeguarding adults board takes note of those connections," she said.
West Sussex councillor Amanda Jupp, cabinet member for adults and health, said: "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."
Sussex Health Care said it had implemented four steps recommended for the company.
A statement said: "Beech Lodge has been regularly inspected by the Care Quality Commission since the events of 2015. The most recent inspection report, published in November 2017, rates the home as 'good'."
Det Supt Fiona Macpherson said police recognised there was a delay and fully accepted the recommendation, but added: "The investigation that was subsequently undertaken was thorough, CPS were consulted about aspects of the case and we made the decision that there was not the evidence to support any criminal charges."
In a separate inquiry, Sussex Police is investigating nine Sussex Health Care homes, including Beech Lodge, amid claims of lack of care of 43 residents, 13 of whom have since died. Two women remain under investigation.
Mr Bates and Mr Lewis are not part of the ongoing police investigation.