A Somerset man died after his GP warned he was at risk of death and a subsequent safeguarding alert was left awaiting the return of a worker who was on leave. His case is one of three examined in a review published on Wednesday, 28 October, which identifies missed opportunities to protect adults living in unsafe conditions.

The men, identified by the pseudonyms Keith, Norman and Roland, died in 2024. All had serious health problems and experienced severe self-neglect, with agencies struggling to coordinate support as their circumstances deteriorated.

The review found examples of persistent and compassionate work by individual practitioners. But it also identified shortcomings in assessing risk, sharing information, resolving disagreements and understanding whether the men could make and carry out decisions about their care.

In Roland's case, a GP visited his home on 22 December 2023 and told Adult Social Care's emergency line that he was at risk of death. Two days later, police carrying out a welfare check found him living in very poor conditions, without heating or evidence of fresh food.

Officers completed their assessment that day, but their safeguarding concerns did not reach Adult Social Care until 29 December. The alert was then logged for a response by the practitioner already involved, who was on leave until January.

A neighbour found Roland, 75, critically unwell on 2 January. He died on 3 January 2024.

An Independent Office for Police Conduct investigation found no evidence that police actions caused or contributed to his death. It nevertheless identified learning about the delay in sharing officers' concerns and the alternative routes available when the force's safeguarding unit was not accessible.

The review also found that Roland's GP surgery continued contacting him by text despite his request for letters and his apparent lack of response to messages. His sister's death could have prompted a home visit, while the extent of his reliance on her had not been fully understood.

Across all three cases, Adult Social Care had not undertaken formal risk assessments. Safeguarding enquiries for both Roland and Norman remained open when they died, without protection plans having been completed.

Norman, 67, had physical health conditions alongside schizophrenia and agoraphobia. He was discharged from hospital on 20 December 2023 with a package of four daily care visits, but declined support and attempts to readmit him.

Uncertainty about his mental capacity remained unresolved. He was eventually readmitted and died on 10 January 2024 from sepsis and community-acquired pneumonia.

Keith, 66, had chronic obstructive pulmonary disease, poor mobility and alcohol dependence. Adult Social Care assessed him in June 2024 but found him ineligible for care and support, believing he was more capable of looking after himself than he reported.

Village Agents repeatedly tried to engage him and raised concerns about his living conditions. In November, a neighbour found him barely conscious, and he subsequently died in hospital.

The review found little evidence that agencies had fully explored why the men were reluctant to accept help. Practitioners also described workload pressures, lengthy referral processes and difficulties securing a coordinated response when risks escalated.

The Somerset Safeguarding Adults Board is calling for clearer expectations about when action must be urgent or immediate, stronger escalation arrangements and persistent support for people who are reluctant to engage.

Professor Michael Preston-Shoot, the board's independent chair, said: "Safeguarding Adult Reviews are not about apportioning blame. They help us understand what happened, identify learning and strengthen how organisations work together to protect adults at risk.

"This review recognises examples of determined and compassionate practice, while also showing that people experiencing severe self-neglect can fall between services when risks escalate, engagement is difficult or professional views differ. We must make it easier for practitioners to act together with urgency, persistence and professional curiosity.

"The Board will oversee the recommendations and ensure the learning from Keith, Norman and Roland informs continued improvement across the safeguarding partnership. We are grateful to everyone who contributed to the review."

Agencies have already introduced changes, including training, revised safeguarding procedures and greater use of face-to-face contact for vulnerable patients. Since December 2025, the council's customer contact centre must notify its safeguarding team when three or more concerns have been raised within 12 months, or when repeated contacts with local teams have not resulted in action.

The report, written by independent safeguarding consultant Suzy Braye, builds on an earlier review of six self-neglect deaths published in July 2025. The board will review its existing action plan alongside the new recommendations.

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