The safeguarding system in Northern Ireland has failed to provide protection to an elderly patient suffering from dementia, who belongs to the most vulnerable adults‘ category.

Stanley O’Neill had not taken a shower for a period of three months and was discovered with a cord being wrapped around his neck.

Even though the guidelines for healthcare were in place, instances of neglect like those mentioned were not reported for investigations into the safety and

A critique was also made of the nursing home as they were found lacking in their openness and transparency regarding the elderly person’s family.

On December 20th, 2021, Mr. O’Neill passed away while being

The family of the patient expressed their extreme sadness and shock after a Belfast Health Trust investigation revealed a number of shortcomings in his healthcare.

Bradley Manor Care Home expressed their sympathy and expressed regret to the family of Mr O’Neill in a statement.

According to their representative, the well-being of their occupants has always been their top priority. However, they acknowledge that they fell short of meeting certain high expectations that were rightfully demanded of them on this specific instance.

The adult social care sector experienced an unprecedented time during the Covid-19 pandemic. Despite offering no excuses, they encountered unique difficulties and faced a highly challenging environment.

The purpose of the adult safeguarding system is to ensure the safety of adults who are vulnerable in the healthcare system. This system is activated when staff, relatives or patients express concerns about their welfare.

During an interview with BBC News NI, the independent organization responsible for overseeing public healthcare in Northern Ireland expressed concern over the inadequate support provided to vulnerable adults in the region.

Sophie O’Neill shared a strong bond with her grandfather and regarded him as the most supportive member of her family. She expressed her deep affection for him by calling him "the rock" of their family.

Stanley O’Neill’s life took a different turn after he was diagnosed with dementia.

The situation at home became too difficult to handle and the person had to stay in nursing homes and hospitals multiple times.

In the midst of the pandemic in January 2021, Mr. O’Neill was admitted to Bradley Manor, a residential facility located in north Belfast. The Belfast Health Trust arranged for his placement at the facility after he had been discharged from the hospital.

Sophie, the granddaughter of someone, reported that her family had started highlighting several incidents that they found worrying.

According to her, there were two falls in the night that were not observed at first and caused concern. However, she eventually discovered that the call bell in his room had been taken away.

The information about the incident was delayed for several weeks until I inquired with the staff. They informed me that they had observed the individual wrapping a cord around their neck, but had promptly intervened and removed it.

Sophie expressed her surprise and confusion over the delay in informing the family about something. She was taken aback and didn’t comprehend the reason behind the delay.

In my experience, there were concerns related to ensuring safety, but no measures were put in place to address them.

Sophie became acquainted with the term "safeguarding referral" when her grandfather was admitted to the hospital in December 2021. It was the first time she had heard this phrase.

Sophie discovered that Mr. O’Neill was not responding when she went to his room at Bradley Manor. He was then taken to the Mater Hospital in Belfast.

Upon my arrival at the hospital, one of the staff members expressed their worries regarding my grandfather to me, according to what Sophie reported.

The hospital staff mentioned that his dental hygiene was the poorest they had witnessed. This prompted discussions about referring him for adult safeguarding measures.

‚Mismanagement of healthcare‘

A man named Mr. O’Neill was hospitalized on December 6 and passed away after 14 days.

The family of the person in question did not receive any notification regarding the adult safeguarding referral until two days after their passing. Furthermore, the investigators were not aware of their death at the time of the referral.

The matter has been brought to the attention of the coroner, who will ultimately decide on the official reason for the person’s passing.

According to Sophie, the purpose of a safeguarding referral is to ensure the safety of an individual. However, in her grandfather’s case, the referral was made too late to provide him with the necessary protection.

The Belfast Health Trust investigated Mr. O’Neill’s case as a severe adverse event at last.

A serious adverse incident is an occurrence or situation that either caused or had the potential to cause significant harm to patients, whether it was intended or not.

The reports of investigations must be handed in within 12 weeks after the date when the incident was reported.

In April of 2023, a preliminary report was sent to his relatives. The report concluded:

As per the report, it was found that every party responsible for Mr. O’Neill’s care had shortcomings.

After conducting an investigation into his situation, educational materials have been distributed to healthcare and social service personnel on how to handle concerns related to protecting vulnerable adults.

The amount of referrals for adult safeguarding in Northern Ireland has risen from 4,778 in 2019 to 6,897 in 2021, indicating a recent increase. It suggests that there has been a growing need for protection measures for adults in the region.

The Department of Health has stated that the rise in reports of adult abuse could be attributed to the fact that the public is more aware of this

Mr. O’Neill’s case has revealed shortcomings in Northern Ireland’s adult safeguarding system, which has been a cause of concern for the Northern Ireland Public Services Ombudsman (Nipso).

According to the ombudsman, Margaret Kelly, there have been multiple instances that have been brought to her attention which indicate that our system for safeguarding adults is inadequate. In her opinion, it is not functioning as it should be.

Frequently, families are the ones who have to bring to the attention of healthcare personnel about possible shortcomings in care, which is unfair.

Over the past few years, the ombudsman’s office has handled eight cases related to nursing and care homes, and in seven of these cases, adult safeguarding was a matter of concern.

The cases brought to the attention of the omb

Ms. Kelly expressed her disappointment that the cases presented only display a fraction of the larger issue at hand. She believes there are many more similar instances that have yet to be

According to her, the safety of the most vulnerable people in Northern Ireland is at risk and there is a possibility that the region may lag behind in terms of

Even though several health ministers have promised to enforce it, Northern Ireland remains the only region in the UK and Ireland that lacks dedicated adult safeguarding laws.

The Department of Health has acknowledged that the current legislation has some shortcomings and has announced that a new bill for safeguarding adults will be introduced once the Northern Ireland Executive and Assembly are operational again.

According to Bradley Manor, the most important thing is the health and happiness of its residents. To improve the quality of care, the facility has already made several adjustments based on the deficiencies outlined in the report.

The Belfast Trust has taken steps to increase its supervision of the care home and has made efforts to introduce measures to improve the quality and safety of care provided.

Sophie shared her thoughts about her grandfather’s situation and suggested that in case any other family faces a similar situation, they should not hesitate to raise their voice to support their loved one.

The problem at hand is the documentary titled "Failed In Care", which can be viewed exclusively on BBC iPlayer for those

Stanley’s story revolves around a safeguarding system that has failed and a family that is searching for answers.

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