‘Help me dad’: Last words of a vulnerable man failed by all systems

Exclusive: ‘Help me dad, I'm not getting on with this place’ - The following audio may be distressing to some readers

Clive Treacey, who had epilepsy and learning disabilities, died on 31 January 2017 after 10 years of being “incarcerated” within hospitals, a major NHS review has found.

His family described how he was “kind, forgiving and oozed humanity.”

They said he loved to write letters “never once forgetting a birthday,” and would always tell people how proud he was of his family.

Mr Treacey had dreams of one day living in a little home close to his family. But he died at the age of 47 at an inpatient unit, after a decade of poor care.

An independent review, commissioned by the NHS, into his life has found a litany of failings by NHS commissioners and the private hospitals responsible for his care in the years and days leading up to his “potentially avoidable death.”

Evidence shared exclusively with The Independent and Sky News can reveal that in the weeks before he died, whilst in a hospital called Ceder Vale in Nottingham, Mr Treacey had made a call to his father with the plea “please help me”.

The following audio may be distressing to some readers.

According to the NHS review, Mr Treacey’s family also had serious concerns after they uncovered new footage of the night he died in which “Cedar Vale staff were observed on CCTV footage repeatedly flashing a torch in Clive’s face.”

This footage was previously not seen during his inquest.

After looking at the footage presented by reviewers, police have concluded their “behaviour did not break safeguarding rules and therefore no investigation was needed.”

However, the review said: “the family remain concerned about an incident recorded in the footage at 8:31pm in which a care worker appears to be speaking with Clive from the open doorway to his room and flashes a torch light at him.

“The police have noted that the CCTV footage does specifically show one member of staff flashing her torch as she stands near Clive’s room. It appears that there are approximately five flashes of the torch by this female. This appears unnecessary given the lighting is already on in the corridor and in Clive’s room.”

‘Make sure you get me a red rose’

Speaking to The Independent about the night before her brother died, his sister Elaine Clarke said he called her at 9:30pm.

She said: “He came on the phone agitated and said ‘people need to be put in prison for putting me in here.’

“He said, ‘They’re coming for me in the morning. It’s finally happening…They’re finally coming. I got to finish packing. It’s happening. It’s finally happening. They’re coming for me in the morning.

“The next sentence he said was, ‘You know, I love ya. And you know, I’ve always known what you done for me.’ And I knew then that my brother was saying goodbye to me. I knew he knew he was dying.

“I said ‘Please don’t go, Clive, please don’t go, come on, talk to me.” He then asked her to buy him a red rose: “Oh, make sure you get me a red rose,’” he told her, “You make sure it’s red.”

The next morning at 7am, she received a call from Ceder Vale hospital, to inform her that her brother had died.

In an exclusive interview with The Independent, Beverly Dawkins, who was appointed to chair the review, said Mr Treacey’s life “held up a mirror to all the failings in the system.”

In each of the 10 findings she said “you knew what was going to happen” because it had happened to others and added “he stood no real prospect of getting out of those placements it is almost like as every year passed, his chances got less. That’s a very sad, very sad story and a shocking, appraisal of lack of progress.”

She said the NHS can spend thousands of pounds a week for someone like Clive to be detained for years yet that money doesn’t seem to be able to be moved to support them to have the life they should have in the community.

“I just feel like people with learning disabilities are never the priority, and there’s no serious time and investment in resolving this problem.”

Ms Dawkins however commended how NHS England had worked with Ms Treacey and her family on the review and says this should be how all reviews are done in the future.

A spokesperson for Cygnet Health Care said: “At the time of Mr Treacey’s death in 2017, Cedar Vale was not owned or operated by Cygnet Health Care. Although we did not take over the service until August 2018, more than a year and half later, we have worked collaboratively with all concerned to support this review and address any outstanding issues and areas for improvement surrounding his sad death, and we will continue to share lessons learned.”