Errol Graham: DWP criticised by report into disabled man’s starvation death

The Department for Work and Pensions (DWP) has been criticised in an official report for the first time for failings that contributed to the death of a disabled man who starved to death after it wrongly stopped his out-of-work benefits.

The much-delayed safeguarding adults review into the death of Errol Graham* is finally set to be published today (Thursday), nearly five years after his body was found by bailiffs who had come to evict him from his flat in a Nottingham tower-block.

There are few recommendations for the agencies that have faced criticism for their role in his death because of the length of time they have had to address their failings – the review was delayed by a judicial review and the pandemic.

But the report still criticises DWP, and it is the latest official publication over the last decade to link the deaths of claimants to the department’s policies and flawed practices, including those relating to the work capability assessment (WCA).

DWP is also facing questions over why it appears to have failed to pass crucial documents to the review, which would have shown that the department knew how unwell Errol had been at the time of his previous assessment in 2014, three years before his benefits were stopped (see separate story).

Errol’s daughter-in-law, Alison Burton, who has fought for justice for her father-in-law since his death, welcomed the publication of the first report to criticise DWP over its actions, although she says she would have liked it to have been more critical.

She said the report shows how DWP “builds these systems quite neglectfully and forgets to put support in place”.

She is still angry and frustrated that DWP insists it has no duty of care to those disabled people who claim benefits through its social security system.

She said: “How long has the department been operating?

“Why on earth have they been operating for so many years without being given strict instructions to comply with certain care laws, including a duty of care?

“Errol is the unfortunate consequence of that.”

Today’s 38-page report, commissioned by Nottingham City Safeguarding Adults Board, focuses on the period between June 2017 and 2018 and describes the “shocking and disturbing” circumstances of Errol Graham’s death.

It describes how DWP decided to re-assess Errol for his employment and support allowance (ESA) in the summer of 2017, three years after deciding he should stay in the ESA support group, for those unable to carry out work-related activity.

Even though Errol had spent two weeks in a mental health hospital after being sectioned in June 2015, his GP was unable to provide more than basic details of his health to DWP, partly – says the report – because the department only asked limited questions.

The report says the ESA113 form the GP was sent “did not request information relating to wider considerations of [Errol’s] mental health such as any barriers to him securing his benefits, risks posed by his mental health when in acute relapse or the impact on his mental health of discontinuing his claim”.

Errol was asked to attend a work capability assessment and when he failed to turn up, DWP made several unsuccessful attempts to contact him, by phone, text and safeguarding visits.

When these visits failed, “no further inquiries were attempted”, says the report.

At the time there was no guidance for DWP staff in this situation, and the report says this was “an omission”, although it says it has since been addressed.

DWP stopped Errol’s ESA in October 2017, which also led to his housing benefit being stopped and his rent not being paid.

The report says DWP guidance allowed the civil servant who made this decision to seek information from other agencies, but the decision-maker decided this was “not warranted”.

The report says: “Decision makers need to understand the potential impact of depression and other mental illnesses, for all claimants and use this knowledge to make reasonable adjustments.”

At the time, the report says, there were no “robust structures to support the DWP Decision Makers to trigger further inquiries of key agencies, in circumstances where there were concerns about a claimant’s vulnerability and an intent to end a claim”.

The report says the “lack of information sharing between agencies was a key issue for what followed”.

The 2014 assessment documents described how Errol could not cope with “unexpected changes” which left him feeling “under threat and upset”, had “active suicidal thoughts”, “very low mood” and was “hearing voices all the time”.

But those documents appear not to have been shared with the review team and today’s report concludes instead that DWP “was unaware of [Errol’s] significant risk factors when acutely unwell, shutting himself away, disordered thoughts, not eating, not drinking and with suicidal ideation”.

Today’s report also makes it clear that DWP’s attempts to contact Errol “did not extend to contacting any other agencies or speaking directly to his GP” and that it had made no attempt to inform Nottingham City Homes (NCH) – his landlord – about his “vulnerability due to his mental health”.

DWP also missed a further opportunity to contact housing services about Errol’s history of mental distress when it informed Nottingham City Council’s housing benefit service that his housing benefit had been stopped.

The report says this was “a key factor because NCH had no record that [Errol] had any mental health needs”, which then “drove their interactions with him”.

After his housing benefit was stopped, NCH made repeated attempts to contact Errol from November 2017 onwards, and on one occasion, in February 2018, a manager spoke to him briefly through his front door, when he reported Errol “was upset and shouted and punched the front door”.

Errol’s gas supply had already been cut off by NCH after failed attempts to speak to him about a gas safety check, which left him without hot water or heating through the winter.

In June 2018, Errol’s body was found by bailiffs sent by NCH who had broken down the front door.

He was 57 years old and weighed just four-and-a-half stone.

A coroner subsequently found he had died of starvation.

The review concludes: “Both agencies [DWP and NCH] were following their processes.

“However, the procedural route that had been taken was based on partial information and misconception about [Errol].

“What we now know is that [Errol] was a man in acute mental distress, who had shut himself away from the world.”

It adds: “Had the combined information been known, it should have set DWP and NCH onto a different procedural route.

“This could have mobilised a multi-agency response providing [Errol] with the vital social, physical and mental health support he needed.”

The review is also critical of other agencies for “a series of missed opportunities to share information”, and it concludes: “Had information been shared, this may have revealed the true nature of [Errol’s] mental distress and mobilised the care and treatment he needed.”

The report concludes that these agencies have engaged in “significant learning” since 2018.

It says DWP has made some improvements since Errol’s death, including the recruitment of “advanced customer support senior leaders” to work with local communities and the agencies that provide support to claimants; strengthening staff training on how mental health may impact on the ability to make a claim or provide evidence for a claim review; helping its decision-makers to identify “vulnerable” customers; and strengthening guidance on what steps to take before stopping benefits in cases like Errol’s.

The report makes just five recommendations.

Among those recommendations, it calls for DWP to work with the national network of safeguarding adults boards to produce a “protocol” that would ensure they alert each other to relevant cases.

It also says NCH should strengthen its “checks and balances when taking high impact actions such as cutting off gas supply without consent or seeking eviction”, and that it should improve the information it holds on tenants’ contacts.

And the report calls on the safeguarding adults board to review its own guidance on self-neglect and service-users who fail to engage with services.

DWP refused to say this week if it planned to amend the ESA113 form (and its universal credit equivalent) to ensure that GPs can provide the wider information that would be useful in future cases and potentially save future lives.

Instead, a DWP spokesperson said: “This was an incredibly tragic case and our condolences remain with this family.”

Lesley Hutchinson, the chair of Nottingham City Safeguarding Adults Board, said: “This review looked into the shocking circumstances of a man’s death where the intervention of agencies exacerbated his problems rather than providing support.

“I offer my heartfelt condolences to all who knew and loved [Errol].

“One of the key conclusions of our review is that if agencies had shared information, it may have revealed the extent of [Errol’s] mental ill health and help mobilise the care and treatment he needed.

“Since [Errol’s] death, agencies have put in place changes to how they work, we have an action plan in place and are monitoring this in a bid to reduce the risks of such a tragedy occurring again.”

*He is referred to in the report as ‘Billy’

Picture: The Nottingham flats where Errol Graham lived 

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