Nigel Robert Holman, 45, was found dead at a hotel in January last year, after a cleaner voiced concerns about a “do not disturb” sign which had been hung on his door for four days.
Mr Holman had been homeless for a number of years and had been left disabled by a serious motorcycle accident which left him in constant pain.
At an inquest into his death, North Yorkshire Coroner Rob Turnbull recorded a narrative verdict that Mr Holman died of an accidental morphine overdose while waiting for help to be rehoused.
Now a review by the North Yorkshire Safeguarding Adults Board - which includes officers from social care services, police, health, housing, the Crown Prosecution Service, the Care Quality Commission and voluntary agencies - has highlighted failings in his care.
“There are a number of lessons to be learned for all agencies involved,” the report says.
It says Mr Holman, who had been living in a tent near Wetherby, contacted the Harrogate Homeless Project (HHP) for help, spending nights at their emergency cold weather shelter. But staff felt the accommodation in the homeless project’s day centre was not suitable for his injuries and they contacted council housing officials saying he should be a priority.
However, the review has found Mr Holman was let down by out-of-hours services over the Christmas and New Year period more focused on deciding if he was eligible for help, than actually helping him.
“It is not possible to say the risks of accidental overdosing could have been reduced by his placement in a different form of accommodation. However the focus on eligibility under homelessness legislation overlooked his care needs and vulnerability,” the report says.
It recommends that Harrogate Borough Council and North Yorkshire County Council should arrange joint staff training to ensure needs are better understood and recommends both work with other district councils to draw-up joint protocols. It praises the efforts of HHP and a GP surgery which helped him.
Jonathan Phillips, independent chair of North Yorkshire Safeguarding Adults Board, said: “We accept the recommendations in this report fully as they will further professionals’ understanding, support wider knowledge sharing and improve services for homeless people in this complex and unique area of adult social care.”
In a statement Harrogate Borough Council said: “This gentleman was an itinerant rough sleeper who approached the council for accommodation, presenting as homeless. The decision at that time was that the council did not have a duty to provide him with temporary accommodation under homelessness legislation.”
It said it had carried out its own internal investigation and changes introduced include a new contract for out of hours response and refreshed training for staff.
Charities have warned of a hidden problem of homelessness in Harrogate. In 2010 figures showed the town had the second highest estimate for homelessness in Yorkshire and Humber, after Bradford.