Safeguarding board highlights string of failures in lead-up to man’s death in Epping Forest

A board responsible for the safeguarding of vulnerable adults in Waltham Forest has vowed to improve after a 69-year-old man was found dead in Epping Forest.

Sydney Piper, who had paranoid schizophrenia, had been living at a care home for several years before he went missing in early 2023.

He disappeared from a clinic at 11.14am on February 23, after telling his care worker he was stepping outside for a cigarette. His remains were found in a tent by the Waterworks Roundabout on March 24, some time after he died.

A coroner recorded his cause of death as a morphine overdose, though no drug paraphernalia had been found near his body.

A spokesperson for Metropolitan Police said his death had been treated as “unexplained, but not suspicious”.

The Strategic Partnerships Board (SPB) inquiry into Waltham Forest Council’s Safeguarding Adults Board (SAB) identified a slew of issues in how Sydney’s case was handled.

Communication “failures” led to safeguarding concerns not being raised in time, the SPB said.

Not noticing that Sydney had left the clinic and sharing inaccurate information  both contributed to the ‘golden hour’ being lost. Police data shows that the first hours of an investigation – the ‘golden hour’ – often tend to impact the outcome.

Sydney had been identified as missing at 11.57am, a full 37 minutes after he left the clinic. By the time the Met had been contacted, he had been missing for more than two hours.

However, the information provided to the force was “incorrect and insufficient,” the board said, and it was not until 9.38pm that the risk to Sydney was escalated from medium to high.

By that time, more than ten hours had passed. Epping Forest is more than 2,400 acres in size, and the SFB said he could have “found his way deep into the forest” and become harder to find.

The board added: “The ‘golden hour’ was lost, hampering possibilities of finding Ivan [a pseudonym used in its report] quickly. Ivan was not a fast walker and had a distinctive gait, so he was not difficult to identify or recognise.”

Though the different bodies worked together in parallel, the SFB said the steps they took were “too slow and bureaucratic in nature,” and did not involve what was “necessary”.

The reviewer added: “He needed human collective action driven by the urgent need to get him back to safety and this can be done if a local protocol is agreed, leaders are trained and well prepared, and staff are trained in how to respond.”

In its multi-pronged response, Waltham Forest’s SAB said it will develop a new protocol to ensure a swifter response to missing persons cases by August this year.

It will also work to “improve the culture” around safeguarding concerns and produce a series of principles for submissions.

The board will also explore improvements in how it monitors safeguarding measures for vulnerable people in residential care – particularly those at risk of going missing.

The SFB attributed the poor response to Sydney’s disappearance partly on human error, and concerns were raised over his carer’s behaviour.

In a prevention of future deaths report, published in March 2024, coroner Graeme Irvine said she had “ignored” him. She had been “sitting in an area away from him while looking at her phone”.

The coroner’s report added: “For much of this period, Mr Piper was out of the direct line of sight of his carer.”

In response, the carer claimed she had not constantly supervised him because she did not wish to crowd him, she was allergic to cigarette smoke, and she had been “resting her legs”.

Sydney, who had spent most of life in care, had required constant one-on-one supervision whenever he was outside.

During the inquest into his death, his carer had accepted she had not read his support plan, nor the relevant procedures she needed to follow that day.

The SPB said it was “impossible” to determine what motivated him to disappear on February 4.

The 69-year-old was described by friends after his death as a “loner,” having become estranged from his family “several years ago,” and a lover of the outdoors.

He had gone missing three times previously, between 2012 and 2020, and admitted to visiting the Essex woodland each time.

They also said there had been a “key change” in his life after a vicious street attack when he was 19 years old. In the subsequent years, he had attempted to commit suicide twice, resulting in medical treatment.

Though he spent much of his time alone, his friends said he was “content”.

Sebastian Mann

Local democracy reporter