An ex-footballer with dementia who died after falling from a height was “stripped of his dignity” while in NHS care, his family said.

Colin Flatt, whose clubs included Leyton Orient and Cambridge United, was shuffled between 12 different settings in the final few months before he died after a fall at Basildon Hospital in September 2021.

An investigation, commissioned by the NHS, found he was given unsafe medication, was injured while being restrained, placed in inappropriate environments and his human rights were breached.

The NHS organisations concerned apologised or said they were working to improve standards of care.

Mr Flatt, 81, died following a fall at Basildon Hospital in Essex.

The independent report described how he had become agitated following a family visit and had stabbed himself in his abdomen with a pair of scissors.

He ran from the ward and fell over the railings of a first-floor landing on to a glass table.

He did not recover from his injuries.

Mr Flatt, who also played for Southend United, Romford, Barnet, and Wisbech Town, had been suffering from memory loss and was admitted to Broomfield Hospital in Chelmsford in May 2021 with a low heart rate.

He was subsequently assessed by the Essex Partnership University NHS Foundation Trust (EPUT) mental health team and diagnosed with Alzheimer’s disease.

The report described how “following several incidents of violence and aggression” he was transferred to Goodmayes Hospital in Ilford, east London, on 9 June and detained under the Mental Health Act.

A Mental Health Tribunal determined that he could be discharged but he was unable to settle at home and he was accepted as a respite placement by a care home with support from a team from EPUT.

He was then transferred to another care home because his needs could not be met, this time with support from the North East London NHS Foundation Trust (NELFT).

Mr Flatt absconded from the home and was returned by the police but it was then decided to send him to Basildon Hospital because of his heart problems, where he he then had the fall.

The investigation, commissioned by NHS England, found a series of failings in relation to Mr Flatt’s treatment and care:

• He was held within hospitals and care home settings without a legal framework “in breach of his human rights”
• A high-risk anti-psychotic drug was prescribed at Basildon Hospital despite his heart problems and the doses “exceeded limits of various trust policies”
• Inappropriate use of chemical and physical restraints by Broomfield and Basildon hospital staff, which also injured him
• His partner’s views were not always taken into account despite her having legal power of attorney
• Mr Flatt was placed in unsuitable rooms at Broomfield including one where there was “continuous hammering and drilling”
• Early morning transfers at 01:00 and 02:00 “which should have been avoided”
• An initial review into his fall was “significantly delayed and incomplete with an absence of analysis”

The report made 17 recommendations with the bulk focused on the Mid and South Essex NHS Foundation Trust (MSEFT), which runs Broomfield and Basildon hospitals.

Mr Flatt’s partner Melanie Leahy said he had been “stripped of his dignity”.

“I watched a strong, capable man walk into hospital seeking help and, within just 19 weeks, he was gone,” she said.

“The lack of proper care, the poor communication, the absence of oversight, and the dangerous overuse of medication” had “stripped Colin of his health, dignity, and life.

“He was a professional footballer, a sailor, and a businessman — proud, independent, and full of humour and kindness.

“To see him deteriorate so rapidly under supposed professional care is something I will never recover from.”

An inquest into Mr Flatt’s death is due to take place in August 2026.

His case has already been heard by the Lampard Inquiry, which was set up to investigate historical failings within Essex’s mental health services.

Ms Leahy’s 20-year-old son Matthew also died in 2012 while he was under the care of the same services.

Christine Blanshard, chief medical officer for MSEFT, said: “We offer our sincere condolences to Colin’s family and want to reassure them that learning and improvements have been put in place since his death in 2021.

“We have already submitted a robust action plan which responds to the points made.”

Paul Scott, chief executive EPUT, said: “My thoughts are with Colin’s family and friends and I am deeply sorry for failings in his care.”

A spokesman for NELFT said: “We extend our deepest condolences to Mr Flatt’s family and loved ones. We hope that the investigation has helped answer important questions about the circumstances surrounding his death.”

The trust said it had implemented changes in line with the report recommendations.

NHS England said it wanted to see “the highest levels of standards delivered across mental health services, supporting our most vulnerable patients and the work of NHS staff to ensure such tragedies do not happen in the future.”