Fred McLernon would never have expected a glossy report on his life and tragic death to be published by the Northern Ireland Social Services Inspectorate.
Before he committed suicide, all the 81-year-old war veteran wanted was to spend his final years in a nursing home among old comrades. Instead, despite numerous pleas, he was left alone in a cold and damp council house. Then, in March 1997, two months after his final request for a place in the home was turned down, he ended his life by placing himself in front of an oncoming train.
A report, Community Care From Policy to Practice: The Case of Mr Frederick Joseph McLernon, was published yesterday and came with assurances from the NIO that lessons would be learnt from the tragedy.
The report found that the social services trust serving Mr McLernon's area in Co Antrim, Homefirst Trust, had failed to respond adequately to his needs, but said that no one was to blame for his death.
One of the most distressing parts of the report details the living conditions endured by Mr McLernon, who was suffering from a deformity known as "claw hands".
A volunteer with the charity Soldiers, Sailors, Airmen and Families Association (SSAFA) called unannounced to Mr McLernon's home in December 1996. He filed a report on his visit, saying he was deeply concerned at Mr McLernon's living conditions and describing him as lonely and depressed.
The house was cold, and the pensioner was dressed for outdoors and had a blanket wrapped around him. Fungus was growing on food in tins in the kitchen, and both the kitchen and bathroom were "hygienically hazardous".
Mr McLernon had for many years set his heart on getting a place in the Somme Nursing Home in Belfast, established specifically for ex-servicemen and women. Both the SSAFA worker and Mr McLernon's GP backed his application.
He had explored every possible avenue to secure a place in the home. In April 1996 he even visited Somme House, after being given the bus fare by the British Legion. He was shown around and had lunch with other residents. Staff at the home told the investigation that Mr McLernon seemed "a respectful and courteous old gentleman who was most unhappy - to the point of desperation". They felt he would have fitted in very well.
However, all this was to no avail. Despite the advice of his GP, the views of the staff at the home and representations from the British Legion and SSAFA, an assessment by a social worker in January 1997 found that Mr McLernon did not meet the criteria for residential care. He took his life shortly afterwards. Mr McLernon was born Frederick Joseph McLarnon into a Catholic family in Antrim in 1916. He joined the British army in 1933, changed the spelling of his name, and effectively became cut off from his family and his roots. He served with the Royal Irish Rifles and the London Irish Rifles for the next eight years and saw action in India and at the North-West Frontier. He was discharged in 1941 for medical reasons after being awarded three service medals.
Mr McLernon lived in England for most of his life and returned to Antrim only in 1988 after his English wife died. He became a daily visitor to the British Legion club in Antrim. The president of the club, Mr Leslie Mercer, said yesterday: "I describe this man in one word, a gentleman."
The Health Minister at the NIO, Mr John McFall, yesterday ordered all trusts and boards in the North to carry out an audit of their community care practice against the 50 recommendations made in the report. It is not expected that any disciplinary action will result from the case.