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Safeguarding Adults Review Alexander (Feb 2022)

Alexander was a 39yr old black British man of Jamaican heritage heritage who had spent most of his adult life in in institutional care due to his mental ill health. He had a diagnosis of paranoid
schizophrenia which was treatment resistant, dissocial personality disorder and comorbid mental & behavioural disorders due to use of multiple psychoactive substances. He was discharged from an in-patient setting into a 24 hour support living placement. Because of his complex needs and previous history of placement breakdown, he was placed in a neighbouring borough. Covid-19
restrictions meant he also had no face to face contact with family members during this period. He was admitted to hospital exhibiting signs of severe dehydration and malnutrition and passed away. A post mortem confirmed he had lost a significant amount of weight in the 8 weeks since his discharge. The cause of his death was a ruptured oesophagus (Boerhaave Syndrome), disseminated intra-vascular coagulopathy and urinary tract infection.

The full report was delayed in publication due to an ongoing Coroners Inquest.

You can access the full report here Alexander SAR Final 2022

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