CLEARER rules have been put in place at a care agency for when to escalate a case when clients are not contactable after a 68-year-old man they were unable to reach for two weeks turned out to be dead, an inquest has heard.
Madeira-born José Fernando Baptista Martins was eventually found dead on Thursday 29 February 2024 and an inquest was opened into his death, which resumed at Morier House yesterday.
Mr Martins had in previous years suffered with health issues and had dementia, which affected his short-term memory and his ability to pay bills and attend appointments.
He had been seen by Jersey’s Adult Social Services, who put him on a care plan with care agency Tutela Jersey.
They originally saw him for three hours, six days a week. After Mr Martins became more independent, this was reduced to one hour a day, during which care workers would help him with bills, appointments and social engagements.
He had “a good relationship” with his support worker, the inquest heard, and it was not unusual for him not to respond if he wasn’t at his flat – for example if he was gardening, while, on one occasion, he had travelled out of Jersey without telling anyone.
The last time his support worker saw him was on Thursday 9 February, when they went for a walk.
On 15 February, they had a brief phone call in which Mr Martins seemed fine, the inquest was told.
After this, the support worker tried – sometimes twice daily – to see Mr Martins, but received no response.
The inquest heard the worker was not initially concerned because it was “not uncommon” for Mr Martins to be unreachable, but when he did escalate the matter on 29 February, the care agency called the police, who found his body at the flat.
There were more than ten attempts to contact Mr Martins, and the support worker went “out of his way” to speak to staff at shops and cafés that Mr Martins frequented, the head of the care agency said.
A consultant pathologist found that the primary cause of death was bronchopneumonia, with some other health issues, some of which came from smoking.
Paul Carpenter, who at the time was acting manager of Tutela Jersey, said the care agency had now implemented clearer rules which meant that if staff haven’t heard from a client for two days, they must escalate the issue. They have held training sessions, and required all staff to read and sign the new rules.
He confirmed that 14 days without contact was “extreme”.
But he said that even if he had gone out of his way to speak to businesses frequented by Mr Martins, the support worker had been “wrong to rely on that kind of information”.
The Viscount, Advocate Mark Harris, who was sitting as Coroner, said he had asked whether the cause of death could be neglect, but that this had a narrow legal definition for coroners which wasn’t met.
He extended his condolences to Mr Martins’s family.
