Welfare officials failed to properly identify the risk of harm to Errol Graham, a severely mentally ill man whose disability benefit payments they cut off and who died of starvation eight months later, an official report has found. An independent safeguarding review into the “shocking and disturbing” events leading to Graham’s tragic and lonely death concluded that multiple failings by the Department for Work and Pensions (DWP), his GP practice, and social landlord meant that chances to save him were missed. Describing Graham as a “man in acute mental distress who had shut himself away from the world”, Nottingham City Adult Safeguarding Board said decisions taken by all three agencies had exacerbated his problems towards the end of his life rather than supporting him. In the months before his death, his disability benefits were stopped, triggering the automatic cancellation of his housing benefit, pushing him into £1,000 in rent arrears. It also led to the disconnection of his gas supplies, and moves to evict him. The emaciated body of Graham, 57, was found by bailiffs who broke down the door of his Nottingham home to evict him in June 2018. He was penniless, had no heating or hot water, and there was no food in the flat apart from two out-of-date tins of fish. The review, which refers to Graham as “Billy”, said: “There were a series of missed opportunities to share information between services. Had information been shared, this may have revealed the true nature of Billy’s mental health torment and mobilised the care and treatment he needed.”. Graham, a grandfather and former amateur footballer with a long history of mental illness, had become disengaged from his family and support services in the final stages of his life as his wellbeing deteriorated and he became withdrawn and socially isolated. The review said DWP and Nottingham City Homes had failed to understand why Graham did not respond to their letters, texts and home visits, and so did not grasp the extent of his vulnerability when they left him without money, food and on the verge of homelessness. Although both agencies had followed their own procedures correctly when they took critical decisions to deny Graham of vital services, the review makes clear such procedures were based on “partial information and misconceptions” about why Graham had refused to engage with them. The review published a poignant note left by Graham and found in his flat after his death in which he eloquently describes the fear, anxiety and anguish brought on by his depression. “All I want in life is to live normally. That would be the answer to my prayers,” he wrote. The review makes it clear that while Graham had demonstrated “self-neglecting behaviours” and had effectively withdrawn all contact with services, the “final detrimental impact on his wellbeing was through the responses by agencies, cutting off access to those basic physical requirements that were essential to his life”. It said a key lesson from Graham’s death was that his refusal to engage with support services did not negate his vulnerability and was not an excuse for inaction on the part of service providers. “Indeed, non-engagement may be a sign of increased vulnerability,” it concluded. Alison Burton, Graham’s daughter-in-law, told the Guardian she welcomed many aspects of the report, in particular the way it identified how shortcomings in services had left Graham down. But she said the DWP must accept a legal duty of care to prevent vulnerable claimants from slipping though the safety net. The chair of Nottingham City’s Safeguarding Adults Board, Lesley Hutchinson, 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].” Nottingham City Housing Services (formerly Nottingham City Homes), the GP practice and the DWP all told the report they had taken steps to improve information-sharing and improve safeguards for vulnerable claimants. An inquest into the case in 2019 found there were “holes” in the safety net around Graham. A subsequent judicial review brought by Graham’s family that sought to prove that the DWP had acted unlawfully by failing to protect him was unsuccessful. A DWP spokesperson said the review recognised the significant improvements it had made to processes since Graham’s death. They added: “This was an incredibly tragic case, and our condolences remain with this family.”