A local care agency has introduced much stricter escalation rules when individuals do not reply to them after it emerged that a client they had been unable to reach for two weeks had died, an inquest heard today.

José Fernando Baptista Martins, born in Madeira, was found dead aged 68 on Thursday 29 February 2024 and an inquest was opened to establish how he came by his death.

Inquests do not aim to apportion blame, but to understand the circumstances surrounding unexpected deaths and whether any learnings can be taken from them.

Held at Morier House (pictured top) this morning, the inquest heard that 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 a 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, but it wasn’t unusual for him not to respond if he wasn’t at his flat – if he was gardening, for example. On one occasion, he had travelled off-island without telling anyone.

He had been relatively independent and would dress “smartly”, the inquest heard.

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.

After this, the support worker tried – sometimes twice daily – to see Mr Martins, but received no response.

The inquest heard he wasn’t initially concerned because it was “not uncommon” for him 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.

The inquest heard of more than 10 attempts to contact Mr Martins, and the support worker “was going out of his way” to speak to staff at shops and cafés that Mr Martins frequented, the head of the care agency said.

There was no indication that anyone else had been involved.

A consultant pathologist found that the primary cause of death was bronchopneumonia, with some other health issues, some of which came from his smoking. But there were no drugs and only a small amount of alcohol in his system.

Paul Carpenter, who at the time was Acting Manger of Tutela Jersey, said the care agency had now implemented clearer rules which mean that if staff haven’t heard from a client for two days, they have to escalate the issue. They have held training sessions, including role-play, 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.