Nikki FoxEast of England wellness correspondent and Matt PreceyBBC East Investigations

Family photo
Colin Flatt, who his partner described arsenic having been a "strong, tin man" ne'er recovered aft falling complete a infirmary pavilion connected to a solid table
An ex-footballer pinch dementia who died aft falling from a tallness had been "chemically coshed, deprived of his liberty, abused and bruised... stripped of his dignity" while successful NHS care, his family said.
Colin Flatt, whose clubs included Leyton Orient and Cambridge United, was shuffled betwixt 12 different settings successful nan last fewer months earlier he died aft a autumn astatine Basildon Hospital successful September 2021.
An investigation, commissioned by nan NHS, recovered he was fixed unsafe medication, was injured while being restrained, placed successful inappropriate environments and his quality authorities were breached.
The NHS organisations concerned apologised aliases said they were moving to amended standards of care.
Mr Flatt died, aged 81, pursuing a autumn astatine Basildon Hospital successful Essex.
The independent study described really he had go agitated pursuing a family sojourn and had stabbed himself successful his abdomen pinch a brace of scissors.
He ran from nan ward and fell complete nan railings of a first-floor landing connected to a solid table.
He did not retrieve from his injuries.

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Colin Flatt (middle of nan seated row) successful Leyton Orient's squad erstwhile they were successful nan aged Second Division successful 1965
Mr Flatt, who besides played for Southend United, Romford, Barnet, and Wisbech Town, had been suffering from representation nonaccomplishment and was admitted to Broomfield Hospital successful Chelmsford successful May 2021 pinch a debased bosom rate.
He was subsequently assessed by nan Essex Partnership University NHS Foundation Trust (EPUT) intelligence wellness squad and diagnosed pinch Alzheimer's disease.
The study described really "following respective incidents of unit and aggression" he was transferred to Goodmayes Hospital successful Ilford, eastbound London, connected 9 June and detained nether nan Mental Health Act.
A Mental Health Tribunal wished that he could beryllium discharged but he was incapable to settee astatine location and he was accepted arsenic a respite placement by a attraction location pinch support from a squad from EPUT.
He was past transferred to different attraction location because his needs could not beryllium met, this clip pinch support from nan North East London NHS Foundation Trust (NELFT).
Mr Flatt absconded from nan location and was returned by nan constabulary but it was past decided to nonstop him to Basildon Hospital because of his bosom problems, wherever he he past had nan fall.
The investigation, commissioned by NHS England, recovered a bid of failings successful narration to Mr Flatt's curen and care:
- He was held wrong hospitals and attraction location settings without a ineligible model "in breach of his quality rights"
- A high-risk anti-psychotic supplier was prescribed astatine Basildon Hospital contempt his bosom problems and nan doses "exceeded limits of various spot policies"
- Inappropriate usage of chemic and beingness restraints by Broomfield and Basildon infirmary staff, which besides injured him
- His partner's views were not ever taken into relationship contempt her having ineligible powerfulness of attorney
- Mr Flatt was placed successful unsuitable rooms astatine Broomfield including 1 wherever location was "continuous hammering and drilling"
- Early greeting transfers astatine 01:00 and 02:00 "which should person been avoided"
- An first reappraisal into his autumn was "significantly delayed and incomplete pinch an absence of analysis"
The study made 17 recommendations pinch nan bulk focused connected nan Mid and South Essex NHS Foundation Trust (MSEFT), which runs Broomfield and Basildon hospitals.

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Colin Flatt's partner, Melanie Leahy said "to spot him deteriorate truthful quickly nether expected master attraction is thing I will ne'er retrieve from"
Mr Flatt's partner Melanie Leahy said he had been "stripped of his dignity".
"I watched a strong, tin man locomotion into infirmary seeking thief and, wrong conscionable 19 weeks, he was gone," she said.
"The deficiency of due care, nan mediocre communication, nan absence of oversight, and nan vulnerable overuse of medication" had "stripped Colin of his health, dignity, and life.
"He was a master footballer, a sailor, and a businessman — proud, independent, and afloat of humour and kindness.
"To spot him deteriorate truthful quickly nether expected master attraction is thing I will ne'er retrieve from."
An inquest into Mr Flatt's decease is owed to return spot successful August 2026.
His lawsuit has already been heard by nan Lampard Inquiry, which was group up to analyse humanities failings wrong Essex's intelligence wellness services.
Ms Leahy's 20-year-old boy Matthew also died successful 2012 while he was nether nan attraction of nan aforesaid services.
'Learning and improvements'
Christine Blanshard, main aesculapian serviceman for MSEFT, said: "We connection our sincere condolences to Colin's family and want to reassure them that learning and improvements person been put successful spot since his decease successful 2021.
"We person already submitted a robust action scheme which responds to nan points made."
Paul Scott, main executive EPUT, said: "My thoughts are pinch Colin's family and friends and I americium profoundly sorry for failings successful his care."
A spokesperson for NELFT said: "We widen our deepest condolences to Mr Flatt's family and loved ones. We dream that nan investigation has helped reply important questions astir nan circumstances surrounding his death."
The spot said it had implemented changes successful statement pinch nan study recommendations.
NHS England said it wanted to spot "the highest levels of standards delivered crossed intelligence wellness services, supporting our astir susceptible patients and nan activity of NHS unit to guarantee specified tragedies do not hap successful nan future."
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