A young man laid dead in his home for weeks while staff at a mental health trust misled his family into thinking he was still alive, a court has heard.
NHS staff kept telling George Fraser’s relatives he was refusing them access to his home, but his inquest was told that there was simply no answer when they knocked on his door.
Even after his best friend contacted staff on July 18, 2024, to say Mr Fraser had not been heard from for a long time, the court heard North East London NHS Foundation Trust (NELFT) failed to alert his family and continued claiming he was refusing them access.
An inquest on Wednesday, May 14, was told Mr Fraser's mother and sister were under the impression he was receiving daily visits from NELFT.
But the mental health service had stopped the visits without telling them.
The final time a care coordinator falsely claimed George was refusing entry, on July 29, his sister went to the flat to try to mediate, where she found his body.
“He had obviously been there for a while,” she said.
When she rang NELFT, she claimed: “They told me to call the police and hung up on me.”
A pathologist told East London Coroner’s Court Mr Fraser was in such advanced decomposition he must have been dead for weeks. No cause of death could be found.
“I can’t get past the thought that my son was lying dead for weeks when you were supposed to be visiting him,” Mr Fraser’s mother told NELFT in court.
“What if somebody had gone in, or done a welfare call, or called the police to kick the door in? There’s always that chance that my son might have been collapsed on the floor but not dead.
“You have offered your condolences, which you can keep, but at no point has anybody ever said, ‘I’m sorry I failed your son’.”
NELFT - which serves Havering, Redbridge, Waltham Forest and Barking and Dagenham - admitted a series of "shortcomings" in Mr Fraser's care but insisted during the inquest that it was already making improvements, including changing policies and offering additional training.
However, coroner Nadia Persaud said she would write a report raising concerns about persistent systemic problems she felt posed a risk of future similar deaths.
Mr Fraser, 37, of Angel Way, Romford, suffered from paranoid schizophrenia, depressive disorder, ADHD and alcoholism.
His sister described him as “kind, considerate, a gentleman in many ways. He was funny and outgoing… he loved with his whole heart. He was an amazing uncle to my children.”
But he would get annoyed if he felt the family were interfering too much, she said, so they entrusted his day-to-day care to NELFT.
As she watched his mental health deteriorate in his final months, she raised concerns with NELFT and was “assured the mental health team would continue daily visits”.
Instead, the visits were stopped without the family’s knowledge.
Mr Fraser was downgraded from the intensive home treatment team (HTT) to the less hands-on mental health and wellbeing team (MHWT).
His new care coordinator only ever met him once and rated him as a low risk, the court heard, even though Mr Fraser was intoxicated and uncooperative during the assessment.
“Myself and my mum made it very clear he was not coping,” his sister told Mrs Persaud.
“We were getting more and more concerned because his behaviour was getting worse and worse and worse. He was getting erratic. He wasn’t eating. He wasn’t washing. I said, ‘he’s not taking his medication’.”
Both said they could not understand why his care was stepped down given he was plainly deteriorating.
The coroner said she would write a formal “prevention of future deaths report”.
“I understand the work that the trust is doing,” she said. “But I remain concerned that within the MHWT there was just no structure to the care provided.
“When they couldn’t get any response from him, no action was taken as actually there was no clear framework in place… it just kept drifting to the next week.
“It just comes up too many times. I’m going to write the preventing future deaths report so that it’s clearly documented that this is an issue that I don’t particularly see improving.”
George’s mother said: “Perhaps it might just stop this happening to somebody else.”
