Leocardo Loney, 83, who vanished from Wembley care home died after 'severe failings' by Brent Council, inquest hears
PUBLISHED: 16:10 07 November 2019 | UPDATED: 16:39 07 November 2019
A pensioner with dementia found dead in a hedgerow two months after he went missing from his Wembley care home died after "severe failings" by Brent Social Services, an inquest has heard.
Leocardo Loney went missing from the Willow House Extra Care Housing, in Vivian Avenue, on August 3, 2017.
CCTV cameras show the 82-year-old leaving the care home, which offered 24 hour on-call care and emergency support for older people and people with mental health needs, just after 5.30pm. But staff only realised he was missing when he failed to show up for breakfast
His body was found in hedgerow in Breakspear Road North, Harefield, on October 14.
An inquest took place at West London Coroner's Court, ending today, which heard that Leocardo was placed in the care home by Brent Council in 2015.
Following the four day hearing his daughters Marie and Denise Loney said in a statement: "The whole family was completely devastated by what happened with dad and we were heartbroken when his body was found.
"While time has moved on our family hasn't been able to. We had so many questions about what happened.
"Some very worrying issues have been raised at the hearing and we now hope that local authorities learn lessons from dad's case in order to prevent other families facing what we have.
"It is absolutely vital that those with dementia and other vulnerable people can always access the care and support that they need."
As previously reported by the Kilburn Times Trinidad-born Leocardo moved to the UK in 1961 and worked for London Transport for 55 years.
A "real charmer" he enjoyed travelling around the capital and discovering new places, gardening, singing and was a very good cook.
The court heard that Mr Loney would often leave the care home unaccompanied and had previously ventured as far as Heathrow Airport and at the side of the M1 motorway, often returned by police.
Although a GPS tracker was placed in his front door key, he often did not take the keys with him and on occasions, the GPS tracker did not correctly pinpoint its location.
Management at Willow House had voiced concerns to Brent Council with increasing urgency over a two-year period asking whether Leocardo's needs could be safely met at the site, but inadequate action on the issue was taken, the court heard.
Coroner Dr Sean Cummings said the registered manager of Willow House made "repeated efforts" to alert the council but found these emails were not appropriately treated or acted upon.
You may also want to watch:
He found that Brent Council was "cumulatively languid" and often "lamentable" in their response. The council was fixated on providing the least restrictive measures, and not safety, he considered.
The court also heard parts of a car were found close to Mr Loney's body in the hedgerow, indicating he may have been struck in a hit-and-run.
Sadly a post-mortem could not reveal the cause of death due to the amount of time Mr Loney had been missing.
Fiona McGhie, the specialist lawyer from Irwin Mitchell who acts for the family, said: "During the course of the inquest Leocardo's social worker accepted that there was clearly a foreseeable risk that harm would come to Leocardo should he leave Willow House unaccompanied.
"It was also clear that as extra care housing, and therefore not as secure as a residential care home, Willow House was not able to offer the level of support that Leocardo needed to prevent him leaving his home unaccompanied.
"It is vital the lessons are learned from the issues identified during the inquest. Whilst there is a balance to be struck between promoting an individual's independence and providing a safe system of care, it is clear that the right balance was not achieved for Leocardo.
"We will continue to support the family at this distressing time to help them come to terms with Leocardo's death the best they can."
The coroner gave a narrative conclusion in which he stated that there were "severe failings" in the care provided by social services.
A Brent Council spokesperson said: "We are deeply sorry about the untimely death of Mr Loney and we have offered the family our deepest apologies and condolences.
"Despite his advancing dementia Mr Loney was happy and social and enjoyed where he lived very much.
Everybody involved in caring for Mr Loney worked tirelessly to strike a balance between keeping him safe and exploring the community which was one of the main things that made him happy.
"The coroner has indicated that we got the balance wrong between Mr Loney's safety and enabling him to maintain a lifestyle that made him happy.
"This is a challenging area of work.
"In response to the tragic circumstances of Mr Loney's death we will continue to work with relevant partners so that every lesson is learned, every risk understood, and every step is taken to ensure, as far as possible, that this does not happen again."