Published: 13:10, 10 January 2018
Professionals should have done more to protect an elderly woman who was living in squalid conditions.
A report by the Kent and Medway Safeguarding Adults Board looked into the case of Beryl Simpson who was found by police in December 2016 with signs of "extreme self-neglect".
She died nine days later after being taken to hospital malnourished.
Mrs Simpson (not her real name) was 82 when she died in hospital and lived at home with her daughter Margaret, aged 62.
The report says the pair lived in a house which was cold, had no working toilet and there was evidence of "extreme hoarding".
Professionals did not speak to Beryl in the last four-and-a-half years of her life, despite the police receiving an anonymous call from a concerned neighbour in April 2012.
The report concluded there was little evidence when contact was made with Margaret that any questions were asked about Beryl's health and wellbeing.
This is despite fears Beryl might have had Miss Havisham Syndrome, a condition linked to extreme self-neglect.
To protect the identity of the people involved in the case, the board removed the real names of those involved and replaced them. It is also not known where in Kent the pair are from.
A number of recommendations have been made to authorities who were involved in the case.
These included Kent Police, Kent County Council, Kent and Medway NHS & Social Care Partnership Trust as well as the woman's GP practice and borough council and Maidstone and Tunbridge Wells NHS Trust.
The report recommends police should consider its adult safeguarding procedures and the Kent and Medway Safeguarding Adults Board should consider the needs of each person living in a house where there are signs of self-neglect.
Professionals should have an understanding of Miss Havisham Syndrome and the ways of intervening in a situation where there is thought a person is a serious risk harm.
"I would like to express deep sorrow and regret that this person has experienced such circumstances" - Deborah Stuart-Angus
The independent chairman who conducted the review, Deborah Stuart-Angus, said: "On behalf of the Kent and Medway Adult Safeguarding Board and our partners, I would like to express deep sorrow and regret that this person has experienced such circumstances and offer sincere condolences to the family.
"The commissioning of this Safeguarding Adults Review, has given us the opportunity to examine detail of a range of complex circumstances, demonstrating our commitment to learn any lessons and share the same with others, so we can all try and prevent these circumstances from developing again.
"We as board fully accept the recommendations made in this review and will continue to work hard to embed the practices to support a preventative approach."
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