AN INVESTIGATION into the death of a young man at an assisted living facility has found a catalogue of errors by health providers.

Nico Reed, who had cerebral palsy and learning difficulties, died in Barrantynes home in Chalgrove on August 22, 2012 after inhaling his own vomit.

A report, commissioned by Oxfordshire Clinical Commissioning Group (OCCG), released today, was damning in its assessment of the events surrounding the 23-year-old's death, calling the care facility 'neither equipped nor prepared' to handle such an emergency.

Along with a 20 minute delay in calling paramedics, staff were unable to perform basic life support without help from the ambulance service and despite Mr Reed being at risk of vomit blocking his airways there was no suction equipment on site.

The report, while acknowledging much had changed in the years since, also criticised how communication with the family was handled after Mr Reed's death.

It said the inexperience of staff in dealing with bereaved families and a change in management at the home from Ridgeway Partnership to Southern Health NHS Foundation Trust in the months afterwards led to a 'high degree of additional trauma' from which the family were still struggling to recover.

The young man had been cared for at Penhurst School in Chipping Norton for 17 years before transferring to Barrantynes in 2010 after an Oxfordshire County Council assessment.

A statement from the family, included in the report, said Mr Reed had been unhappy with the move but added it was their treatment by Southern Health while 'utterly grief stricken' that 'broke' them.

The report identified five key 'areas of learning', which cover the 'rushed' move from Penhurst, funding, co-ordination between providers, ensuring individualised care, and mental capacity assessment.

It also included 19 recommendations, ranging from keeping family informed of investigations to making sure full risk assessments are in place, which OCCG say will be adopted in improve care for people with complex needs.

Southern Health chief executive Dr Nick Broughton said the decision not to involve the family in its initial investigation was a 'mistake', adding there had been a 'great deal' of improvement since.