Jake loved being a dad. But following a period of ‘escalating vulnerability and fragmented support’, the ‘struggling’ father in his 30s was found dead in his new accommodation in Salford.
Fragmented support, missed opportunities, and inconsistent care by Salford’s adult social care team may have contributed to his death, a new report has found.
A serious case review on ‘Jake’, whose name has been changed, was published in a ‘thematic’ report on individuals with multiple support needs. People who are ‘passed like ping pong balls from one person to the next with no-one actually helping them’, according to family members.
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Jake struggled with his mental health and addiction to prescription and non-prescription drugs. Because of this, he was ‘often passed between services, with mental health services unable to engage due to active substance use, and substance misuse services limited in their ability to intervene where mental health needs were untreated or considered too complex’, according to the report.
The review also found the stigma of having an addiction to drugs may have influenced how support was offered, and how risk was perceived and managed.
The review found there were ‘missed opportunities’ to help Jake and others.(Image: Manchester Evening News)
After a car accident that saw him hospitalised with debilitating injuries, Jake was discharged ‘without coordinated care’ and spent a period of time homeless, living in temporary accommodation. He was sometimes placed in homes that were unsuitable for his reduced mobility needs, and so struggled to carry out basic care like bathing or see his son.
The housing instability compounded Jake’s vulnerability at critical points, said the report, and despite Jake himself expressing he was ‘struggling’, ‘his concerns were documented by professionals but don’t appear to be explored in any greater depth’.
Reports of exploitation, signs of self-neglect, and suicidal ideation, were also not treated with enough gravity.
“Safeguarding procedures were not triggered early enough, and where concerns were raised, they were either not progressed, or multi-agency responses lacked momentum and clarity of purpose,” the report said.
Shortly after moving into new, permanent housing, Jake overdosed on medication.
Jake’s mum, who acted as his carer and guardian, and also cares for her elderly mother, told social workers she had seen a distinction in how the adult social care service had worked for her son.
“My elderly mum has support ‘thrown’ at her, yet my son couldn’t get anything without a ‘fight’,” she said.
Jake was hospitalised following an accident with a car. (Image: Copyright Unknown)
Jake’s case was considered alongside six other men, who all ‘slipped through the net’ of the system due to ‘cocurrent needs’. These include ‘Andrew’, an army vet who died in August 2025, after a history of mental ill health, substance misuse, self-neglect, and hoarding; and Matthew, a loving father of two with substance abuse issues, who took his own life following suspected domestic abuse and a relationship breakdown.
The report concluded: “Despite being known to multiple agencies, individuals such as Jake, Mathew, Steven and Francis experienced fragmented support, missed safeguarding opportunities, and inconsistent care coordination. Their experiences highlight systemic shortcomings in multi-agency working and underscore the need for more integrated, trauma-informed and person-centred safeguarding approaches.”
A Salford City Council spokesperson said: “This review raises serious concerns and important learning for all agencies involved in safeguarding adults in Salford. The council and partners will be developing a multi-agency action plan which will be overseen by the Salford Safeguarding Adults Board.
“We are committed to learning openly from the review and strengthening how services work together to recognise risk and support people with complex needs. To protect the privacy of those involved, we are not able to comment beyond the published review on individual circumstances.”