Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0008, written 11 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2016 |
|---|---|
| Reference | 2016-0008 |
| Deceased | Colin Williams |
| Coroner | Elizabeth Carlyon |
| Coroner area | Cornwall |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive of Cornwall Council
(Director of Adult Care, Health and Wellbeing)
Local Adult Safeguarding Board
CORONER
| am the Senior Coroner for the coroner area of Cornwall
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
{
INVESTIGATION and INQUEST
Colin Keith Williams
CIRCUMSTANCES OF THE DEATH
Colin Williams was found dead at his home address, 18 Tregonissey Close, St Austell
on 9" April 2013. He was found lying on the kitchen floor with three jackets on, over his
top and trousers in a state of decomposition. The house was well heated but in a
neglected state (plates with mouldy food around house, alt surfaces covered with
hoarded items/medication) with evidence of Mr Williams excessively abusing alcohol.
He was last known to be alive on 17" March 2043. It was not possible to establish the
cause of death or whether neglect played a part in the death on the evidence at inquest.
Mr Williams was well known to numerous agencies e.g. Social Service, GP, police
RCHT, social houses and was known to be a vulnerable adult and to self-negtect ill
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
Mr Colin Williams was known to numerous agencies and personnel. At inquest
evidence was given from Ocean Housing, Adult care, Health and Wellbeing, Taylors of
Grampound, the Police, Royal Cornwall Hospital (together with minutes of Complex
planning meetings arranged by Cornwall Council on 14.11.12, 13.03.12) the extent of
his complex needs and tendency to self-neglect, particularly when under the influence
of alcohol. Despite being known to have complex needs his body was not found for
some weeks, Those at inquest gave evidence that due to the large number of potential
agencies involved in his care, his age (below 65), and the fact he had variable mental
capacity due his chronic alcoholism (no mental health diagnosis) it made it difficult for Mr
Williams to know which agency provided what service and whether they were free or
not. This ted to agency “blindness” preventing him from accessing help/funding
particularly at a time of crisis (especially when he lacked capacity due to alcoholism).
An example was given by Ocean Housing who had been involved with Mr Williams since
2011. Initially he was provided support through this tenancy which was funded by
Cornwall Council supporting peopte budget. In 2011 the way funding was provided was
changed and Mr Williams no longer qualified. An independent living service was set up
in lieu which clients had to contribute towards. From this time forward Mr Williams did
not engage as he had difficulty in understanding the structure. His funding was made
more complicated by hospital admissions/care home placements which meant on
occasions he was left without funds due to the necessary paperwork being completed -
which he was unable to complete or understand on his own.
Those at inquest considered that this was not an uncommon scenario; particular when a
client had both health and social issues and this was made even more difficult if they
were drug and/or alcohol dependant.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisations have the power to take such action.
To review the structure and interagency approach in supporting clients with multiple
social and health needs (in particular to those with drug and/or alcohol dependency) to
provide a more “joined up” approach to the client with consideration of key workers.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 11 March 2016. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent_a copy of my report to the Chief Coroner and to the following Interested
Persons s.r to the LOCAL SAFEGUARDING BOARD. |
have also sent it to Public Health Commissioning Group who may find it useful or of
interest.
am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
11 January 2016 SIGNED BY CORONER - DRE E
EYpaletti rma’ Gtryon — CARLYON
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