Description

This report demonstrates how unfocused service planning, poor interagency coordination, and a lack of follow-up can subvert the mission of agencies responsible for protecting vulnerable adults. A mentally retarded beneficiary of a $200,000 trust fund under a conservatorship was kept locked in a small, filthy, barren room in a frail, elderly woman's home for the last years of his life. He died as a result of neglect and deprivation because local social services and mental retardation offices, as well as court-appointed conservators and a community-based physician, all failed in their duties, leaving him to spend his last days sitting on a commode, with little or no stimulation, while his few social skills deteriorated from disuse.