Shortfalls and missed opportunities: report on homeless man Musa’s death published

A number of “missed opportunities” are catalogued in a report on the death of Musa Sevimli, a 63-year-old man who died from a combination of a heart attack, hardened arteries and pneumonia at the Stoke Newington bus stop in which he lived.

The report, by social work academic Professor Michael Preston-Shoot, focuses on the period between his eviction from a hostel in September 2018 to his death in July 2019. It finds that “a formalised coordinated approach to responding to [Musa’s] needs and the risks to which he was exposed” was absent in his case.

It also reveals that on two occasions, once in November 2018 and again in the month before his death, Hackney Council’s adult social care department declined to make safeguarding interventions when concerns were raised on Musa’s behalf by outreach workers who continued trying to help him throughout.

Speaking to the Local Democracy Reporting Service (LDRS) on this aspect of the case, Preston-Shoot said: “I don’t think that there is a clear, reasonable and rational explanation for the decision. 

“Was there evidence that Musa had care and support needs? Yes. Was there evidence that he was experiencing abuse and neglect, for this purpose self-neglect? Yes. Was there clear evidence that he was unable to protect himself because of his care and support needs? Yes.

“Those three criteria were met. Therefore in my judgment there should have been an adult safeguarding enquiry. To be fair to Hackney, my judgment has been endorsed by those people in the council who have participated in the review. It is fully accepted by the Director of Adult Social Services in Hackney and by her colleagues.”

The report paints a picture of a “lack of confidence” among staff to take the lead in complicated situations and an accompanying absence of agreement between different agencies on whether Musa had the ability to make decisions for himself, despite evidence of his self-neglect.

Preventative

The document, the purpose of which is not attribute blame for Musa’s death but to promote good practice to prevent similar incidents, makes clear the importance of staff trying to understand a person’s past trauma or background and seeks reassurance on the use of interpreters and advocates, with a language barrier frequently proving an obstacle in his case.

A “significant omission” is made at the outset of Musa’s case after he was evicted from a hostel run by St Mungo’s in September 2018 without a meeting to safeguard his future, following health and safety concerns over the state of his room and warnings over non-engagement with services. According to Hackney Recovery Service (HRS), he “deteriorated quite rapidly” following his eviction.

Musa’s first stretch of time at the bus stop was between September and November of 2018, during which time London Street Rescue raised a safeguarding concern on his behalf over his alcohol misuse, health issues, refusal of temporary accommodation, and self-neglect including poor hygiene, very dirty clothes and refusal to accept transport to A&E and clean clothes.

This period was also marked by a refusal on Musa’s part to accept help to find temporary accommodation, though the report notes that “he was possibly reluctant to leave all of his belongings in the bus stop for any length of time,” while questioning whether it was reasonable to expect him to attend appointments at council offices. 

According to Preston-Shoot, “no assessment of [Musa’s] decisional capacity or consideration of self-neglect procedures…was evident” at this time, though he continued to be visited by outreach workers and housing officers.

While “doubts” about his decisional capacity did begin to emerge towards the end of this first period living in the bus stop, he was deemed to have capacity at a visit from London Ambulance Service, which the report describes as a “missed opportunity to complete a formal mental capacity assessment.” 

On the 14/15 November, after a member of the public made a 999 call, Musa was taken to the Whittington Hospital with a chest infection and necrotic pressure ulcers.

On the same day, Hackney Council had made a decision to not commence an adult safeguarding enquiry on the basis that he had no care and support needs, with the department adding that he had been “living an itinerant lifestyle for a decade,” and had “clear tendencies towards poor self-care,” a decision highlighted by Preston-Shoot as “very questionable” and based on “flawed” reasons.

Assumptions

Preston-Shoot added: “Unconscious bias may have played a role. Those kinds of stereotypes to which we are all more or less guilty, may well have played a part in how some practitioners responded to Musa. I am certainly saying that lifestyle choice assumptions about people’s mental capacity to take particular decisions were influential in this case, as they were in so many others. 

“This case is not unique. It is very common for me to hear people say, ‘“This is a lifestyle choice. This person has capacity. There is therefore nothing we can do.” The assumption there is nothing we can do is wrong in law, and equally there is evidence that sometimes practitioners and services jump too quickly to an assumption that this is a choice. 

“The more you find out about people’s life experiences, the more questions you will have about the assumption about lifestyle choice and the more you might recognise that trauma and loss play a considerable part in the lives of people who self-neglect and people who are homeless, and some of what they then do is in a sense a coping mechanism. If we do not consider that, we are biased.”

The social work expert added that he “cannot exclude the possibility” that Musa would have been treated differently if he had not been from an ethnic minority community, with “inadequate attention [paid] to communicating with him in his first language.”

Treatment

Musa stayed in hospital until 3 January, with his care making reference to mild small vessel disease, the most common cause of vascular dementia. A high risk of self-neglect was also established in hospital, with a 30 November mental health review concluding he lacked capacity, and he was discharged into the dementia unit of an Enfield nursing home where he stayed until the end of May.

After not meeting the criteria for funding for his care, other housing had to be sought for him. Musa’s behaviour at the home is recorded as “very challenging,” with an assault of a female resident on 11 January resulting in an adult safeguarding concern being made to Enfield Council, though no multi-agency or cross-borough meeting.

An assessment completed in the nursing home at the beginning of May concluded that he did have mental capacity, was independent and had no eligible needs, and Musa was offered a hotel room as temporary accommodation on 28 May, but had returned to the bus stop where he would live until his death in July by 30 May.

Questionable

At a “crucial moment” in his case in June, Hackney adult social care declined a second safeguarding referral on the basis that Musa was of no fixed abode, did not have any eligible care and support needs and had made himself intentionally homeless.

This decision is underlined as “highly questionable” by Preston-Shoot and challenged at the time by Enabling Assessment Service London (EASL), whose staff, the report says, “knew Musa well and where the focus was attempting to prevent further rapid deterioration.”

Towards the end of his life, Musa was served with two enforcement notices trying to make him leave the bus stop, an approach characterised by Preston-Shoot as a “response to public concern” and questioned due to the lack of evidence that such notices could be understood or that he had the capacity to comply with them.

Shortfall

One aspect of the case that Preston-Shoot admits he finds “surprising” was that, despite the widespread and long-running community concern around Musa’s case, there is little evidence of discussion of it at a number of high-level panels within the Town Hall, with minutes not available for the one forum at which it may have been examined.

He added: “I would regard that as a shortfall. Musa’s case should have been the subject of multi-agency meetings really routinely, both before he was admitted to Whittington Hospital and after he was discharged from the nursing home into temporary accommodation which he never took up because he went back to the bus stop. 

“Things rapidly escalated from there, including concerns expressed by citizens in Hackney. I would want to applaud the citizens in Hackney who endeavoured to raise concerns. 

“Musa’s case should have been the subject of multi-agency meetings really routinely, and the more there was evidence that the approaches taken, whether community enforcement or other approaches that those approaches were not working, then the greater the imperative to seek legal advice and to bring cases like Musa’s to the attention of senior leaders in the local authority.”

Musa died four days after a visit to assess his mental health by a group of practitioners ended in a disagreement between medics over whether Musa had mental capacity resulted in a decision to leave him at the bus stop and return for a further mental health assessment on 30 July.

The report says that this visit was “arguably a missed opportunity to safeguard Musa’s health and wellbeing,” with him being described as this point “severely unkempt, his clothes soiled. He was unable to move his left foot, which was dark in colour and without sensation.”

Twelve recommendations

Preston-Shoot’s report makes twelve recommendations as part of the report, including for reviews of meetings about homeless people to ensure a “structured approach” and on practitioners’ legal literacy.

He said: “I am optimistic that some lessons have already been learned, hence the emphasis in the report on the architecture now in place in relation to multi-agency meetings and the co-location of different practitioners together. 

“None of us can rule out that something like this will never happen again. I wish we could rule that out, but none of us can be so optimistic that we can say this will never happen again in Hackney.”

The report establishes Musa’s past history as much as it is able, adding some detail to the life of a man whose death caused shockwaves throughout the community, with vigils held at the bus stop at which he died.

He had been recorded as saying in the months before he died that “something brings [me] back to the bus stop,” and Preston-Shoot confirmed that a since-closed community centre with which he had been involved was located nearby.

Musa had a niece, and a sister who died around one year before his own death.

The review details Musa’s long history of alcohol and drug dependency, for which he was prescribed methadone. It is also thought that he had two sons living in Turkey, and that he had worked in a cafe and in the rag trade.

An London Ambulance Service spokesperson said: “We would like to offer our sincere condolences to Mr Sevimli’s family and friends. 

“We recognise the decision to deem Mr Sevimli as having mental capacity when we responded to him on 11 November 2018 could have been documented better and since then we have put in place wider training for staff and volunteers around mental capacity.”

Cllr Chris Kennedy said: “This was a tragic incident of a life cut short, and my thoughts remain with his family and friends.

“We accept all of the recommendations in this review, and have already implemented many of the lessons it outlines. 

“Hackney takes safeguarding our most vulnerable residents very seriously, and we were glad that this was recognised in the report.”

You can read the full review here.

EDIT: This article was updated at 10:52 on 26 January 2021 to include a statement from London Ambulance Service.