A man with learning difficulties living in supported accommodation was admitted to hospital four times with severe head injuries that "could actually have killed him" after failings in his care.
According to a Safeguarding Adults Review in Trafford, the man, known as John, had four serious falls in the space of three weeks and was admitted to hospital each time.
The independent author of the Safeguarding Adults Review said: "You can see how this vulnerable man could easily have died."
The Trafford Strategic Safeguarding Partnership - consisting of Trafford Council, Trafford Clinical Commissioning Group and Greater Manchester Police - oversee the borough's adult social care provision.
The partnership has acknowledged and apologised for the "failings in the way John’s care had been coordinated" and said it has already introduced changes and is seeing improvements.
In 2016, John was mistakenly given twice his usual dose of medication by a GP surgery just before his falls happened that May.
The medication was originally prescribed to help with his insomnia and made him drowsy.
Administering double the normal dose made him even more sedated and at "greater risk" of falling, the independent review author found.
The author said John had recounted being seen by 33 different members of hospital staff during one of his admissions, none of whom knew him or had become attune to his needs; particularly surrounding his communication due to his learning difficulties.
They added hospitals were "slow to assess his mental capacity" and "didn't think sufficiently about the place they were discharging him to". He had previously returned to his accommodation within the community where he was being supported but where he'd previously had falls.
The review author said safeguarding alerts started to accumulate about his falls, but it wasn't until John's fourth admission to hospital, his first to Trafford General, that more care and thought was put into his needs.
John was ultimately provided with safer, ground floor accommodation to help manage his risk of falls after his fourth hospital admission.
The author of the review said "there was a lot of learning for professionals" from this case; including for the GP practice and John's care provider.
As a result, the review's author said it was important to ensure regular assessments of someone's needs, plans to meet those needs and communication channels between professionals were in place in future.
A spokesperson for the Trafford Strategic Safeguarding Partnership said: “We recognise there were failings in the way ‘John’s’ care had been coordinated and for that we apologise.
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"All members of the partnership have made strong commitments to introduce changes to procedures to avoid similar situations happening again and we are already seeing improvements in this regard."
They explained that, as a result of this particular review, a forum which reviews strategy for patients with learning disabilities in hospital has been set up.
This week was Trafford's Safeguarding Adults Awareness week of action, in which professionals in the service reviewed what they had learned from this case to ensure improvements were locked in.
The spokesperson added: "All learning and good practice that emerges from our Trafford Safeguarding Adult Reviews are shared at a local and national level.”
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