A coroner has demanded improvements after public-funded carers took a vulnerable man to the pub when they were supposed to helping him cook and clean.
Amputee Omar Abdi Ahmed, 54, was found unresponsive with hypothermia at his flat in Forest Gate on November 15.
Paramedics found him lying in a foetal position, suffering from septic shock and a bedsore, wearing a soiled incontinence pad.
A diabetic, Mr Ahmed received care from community nurses, plus multiple visits per day from carers, after he had one leg amputated and the other partially amputated.
Yet paramedics found his flat “unheated and unsanitary,” wrote Graeme Irvine, senior coroner for east London.
One of Mr Ahmed’s legs was “dressed in a dirty bandage that had not been changed for two weeks”.
He died in hospital five days later, with hypothermia listed as the primary cause – but pneumonia, diabetes and ischaemic heart disease given as contributing factors.
Mr Irvine has issued a report to Newham Council and the private care company it contracted to look after Mr Ahmed, raising concerns that others may die if improvements are not made.
Sunlight Care Group, based in Balaam Street between Plaistow and Canning Town, was supposed to help Mr Ahmed with “cleaning, personal hygiene, preparing meals and mobilising”.
But, wrote the coroner, after a July inquest: “Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals.
“Instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.”
The “prevention of future deaths” report was also sent to the East London Foundation NHS Trust (ELFT), which provides community healthcare in Newham, Tower Hamlets and Hackney.
Mr Irvine found ELFT’s district nursing team were “under-resourced and demoralised” and “lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment”.
On top of that, nobody from any of the agencies challenged his “poor decision-making” over his finances.
Mr Ahmed would frequent a local pub and café, but then not switch on his heating or buy “nutritious food and cleaning materials” for his home.
His heating was switched off when he was found at home in winter with hypothermia and pneumonia.
Mr Irvine criticised “poor standards of communication between the domiciliary care company, the local authority and NHS trust”, which he found “resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health”.
He told all three agencies: “During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken.”
He gave them until mid-September to provide “details of action taken or proposed to be taken”.
He also forwarded his concerns to the Department for Health and Social Care, the Care Quality Commission (CQC) and Newham’s director of public health.
Sunlight Care Group, registered as Vista Care Solutions on Companies House, is registered with the CQC as two separate services – one in Redbridge and one in Newham.
Redbridge, set up in 2023, has never been inspected. Newham, in Balaam Street, was last inspected in 2019 and rated “good”.
The firm did not respond to our requests for comment.
A council spokesperson said: “Newham Council expresses our deepest condolences to Mr Ahmed’s family and friends.
“We are working closely with ELFT and the care provider to ensure all required actions are taken, including a multi-agency response to the prevention of future death report.
“We have also referred Mr Ahmed’s sad death to our Newham Safeguarding Adult Board to be considered for a safeguarding adult review.
“This will be subject to scrutiny by the independent chair of the Newham Safeguarding Adult Board.”
An ELFT spokesperson said: “The trust would like to express its deepest sympathies to Omar Ahmed’s friends and family.
“We are reviewing the comments made by the coroner after writing to us. We remain committed to learning from any shortcomings and addressing them to improve the care our service users receive.”
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