A 69-year-old Oldham man named 'John' in a safeguarding review died after spending days on the floor of his house in multiple occupation (HMO) while maggots infested wounds in his legs, a report has found.

John was discharged from Royal Oldham Hospital just two weeks before the fall that led to his death. The recently published report from Oldham Safeguarding Adults Board found that the local authority and medical professionals at the hospital missed opportunities to support him.

Prior to his death, John was treated for severe malnourishment and an acute kidney injury. At the time, he told staff that he did not feel safe in his home, as he lived in an HMO with five other people, all of whom had serious alcohol and substance abuse issues.

John was told that a housing application was 'unlikely to be accepted', and 'possibly as a result of this information' agreed to be discharged from the hospital back into the HMO, the report said. But hospital staff were unaware of the extent of the horrific conditions John faced at home.

His home had no central heating or hot water due to a broken boiler. There was no way to reheat or cook food as there was no functioning microwave, kettle or cooker at the property. John also struggled to access the shared bathroom on the first floor due to mobility issues and the state of the facilities.

The report found that some of this information had previously been flagged to the adult social team, which should have been shared with health professionals before the discharge.

During his hospital stay, John was referred to the council's adult social care team – his third referral in just over a year – and to Age UK. While staff did visit John's address and call after he returned from hospital on October 18, they failed to inform other agencies that their attempts to contact him had been unsuccessful.

It emerged later that John had fallen at home soon after his hospital discharge and was unable to call for help. For several days, he remained on the floor, developing pressure ulcers and becoming 'covered in urine and faeces'. When his daughter discovered him on November 5, there was 'evidence of maggots on his lower legs'. John was hospitalised but passed away on November 7.

The review found there were 'several missed opportunities' to fully assess John's care needs and follow up on safeguarding concerns after his hospital discharge. It also found a lack of evidence of sufficient communication between hospital teams when caring for John, and it was unclear if medical teams discussed with ward staff whether the safeguarding concern was addressed and if discharge was going to be safe.

The report noted that John might have felt ashamed because of the poor living conditions of his home, and as a result was reluctant to ask for or accept help that required social workers to enter his home. It reflected there were further 'possible missed opportunities' for the council's housing team to involve them in addressing whether the landlord could have been made to address the poor living conditions at the property.

Dr Henri Giller, the Independent Chair of Oldham Safeguarding Adults Board, said: "We extend our sincere condolences to the family and friends of John following his death. The safeguarding review identified areas where care did not meet the expected standards, and we are deeply sorry."

He added: "The review has been completed, and we have taken the findings extremely seriously. Actions have been taken to strengthen how we support and safeguard adults who may be vulnerable. This includes improving communication and coordination between services, particularly when planning hospital discharges. Our priority is to learn from this case and ensure that such failings are not repeated."

The report calls for improved information sharing and joint working between health and social care teams, as well as greater involvement of housing services in safeguarding adults living in poor conditions. The board has committed to implementing the recommendations to prevent similar tragedies in Oldham.