The Police Ombudsman has recommended that two police officers be disciplined after a police search of a man's home in the Strathfoyle area of Derry/Londonderry failed to find his decomposed body, which was lying under a blanket on a sofa in the living room.
The man, who was dependant on alcohol, had not been seen for more than a week when police were alerted by a neighbour to concerns for his safety.
Mr Hutchinson said the circumstances of the man's death are poignant:
"I think there is a lesson for all of us in official organisations that vulnerable people, such as those dependant on alcohol, are still falling though the cracks in the system. If it was not for the persistence of the man's neighbour the discovery of his body would have been delayed even further."
The incident began when on Sunday, 14 September 2008 when a neighbour of the man reported she had not seen him for more than a week and said this was unusual.
The woman reported the matter to police again the following day, Monday 15 September 2008 and police officers were sent to the man's home.
A police officer, who was about to go inside the house, was cautioned by a colleague about the awful state of the property. Undeterred, and without either protective clothing or a torch, the officer went inside and began a search. The officer said the main living room windows were partially boarded up, the curtains were drawn and the lights were not working, all of which made visibility poor.
The officers left the house without finding the body, which was under a blanket on a sofa in the room.
The police made additional inquiries with the Housing Executive and established that the man still lived at the property. Despite inquiries with Social Services and attempts to contact the man's family, they were not able to get any more information on his whereabouts. Local police patrols were informed to report any sightings of the man.
The following day, Tuesday, 16 September 2008 police officers went back to the man's property to establish if he had returned home. A police officer who had previous knowledge of the house, went inside and began an initial search, but without success.
When he came outside a neighbour told the officer that the man ate and slept in his living room and that a Housing Executive official had previously found him asleep under a blanket on the sofa.
The officer returned inside and found the man in the position described by the neighbour, his body decomposing.
Police Ombudsman investigators examined the house and found them in an extreme state of disrepair, with no working toilet, rubbish half a metre deep in places and generally in a condition utterly unsuitable for human habitation, and with dead maggots in places.
The Police Ombudsman, Al Hutchinson, has recommended that two police officers be disciplined: one for a failure to deal properly with the initial report made to police, the other was the police officer who carried out the initial search.
Mr Hutchinson also recommended that police in the district be reminded about keeping an index of properties or locations which present issues of concern , such as health and safety issues, vicious dogs etc.
"This would help officers by ensuring they were well informed, prepared and equipped for some of the difficult situations, they are faced with" he said.