Samuel Pearson

RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE 
DEATHS 

   1.  THIS RESPONSE IS MADE ON BEHALF OF  

London Borough of Bromley Council 

2.  REGULATION 28 REPORT 

This response follows a report by Assistant Coroner Jonathan Landau dated 10th 
November 2022 

3 

INVESTIGATION and INQUEST 

On 4 February 2022 an investigation was commenced into the death of Samuel Robert 
Pearson, aged 29.  The investigation concluded at the end of the inquest on 12 October 
2022. The narrative conclusion of the  inquest was: 

A van crashed into Samuel’s property on 20 June 2021.  The accident caused a 
traumatic deterioration in his mental health.  He was moved to accommodation that 
increased his anxiety, and no services were provided to mitigate that.  On 6 July 2021, 
He took an overdose of Pregabalin and alcohol to help him sleep and he accidentally 
died as a result. 

4 

CIRCUMSTANCES OF THE DEATH 

Mr Pearson had complex mental and physical needs.  He moved into his own 
accommodation in March 2021 following a period of good partnership working between 
relevant organisations.  In June 2021, however, a van crashed into his home 
necessitating an emergency move to alternative accommodation.  Mr Pearson struggled 
with the trauma of the accident, contributed to by the unsuitability of his temporary 
accommodation (a budget hotel). 

5 

CORONER’S CONCERNS 

The MATTERS OF CONCERN set out by the coroner are that  – 

(1)  Whilst there was good multi-agency working before Mr Pearson moved into his 
own accommodation, that was lacking when it became necessary to move him 
on an emergency basis despite the circumstances increasing his anxiety and 
vulnerability.  Partnership working and sharing of information between the 
authorities may help mitigate risk in future cases of emergency decants. 

(2)  In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP 
to the ADAPT service but at the time there was a 2-3 backlog in screening referrals 
and the GP was not made aware of the capacity issues.  A robust contingency plan 
would ensure that referrers are informed when services are not able to meet usual 
service expectations. 

I heard evidence of openness to remedy these matters, which is welcome, but plans were 
at a very early stage by the date of the inquest. 

1 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 6 

ACTION TAKEN/TIMESCALE 

1. 

2. 

 In respect to the Coroner’s concern (1), emergency decants are dealt with by 
Housing Associations in the London Borough of Bromley.  The Local Authority’s OT 
(Occupational Therapy) service were not made aware of the emergency move/decant 
of Mr Pearson at the time it took place.  When made aware the OT service raised their 
concern by email to the relevant personnel regarding the temporary accommodation 
provided.   Arising from this is the need for the relevant Local Authority personnel to 
be notified as soon as possible in the event of future emergency decants, when a 
vulnerable person subject to social care involvement (e.g adult social care/OT) is 
moved.   

In respect of London Borough of Bromley’s largest provider Clarion, Senior 
Management in the Housing Department (LA) made contact with a Clarion Manager 
on the 14/12/22 and 29/12/22, raising the need to review their Emergency Decant 
Policy around notification of emergency decants to LBB where there is a vulnerable 
household member.  Clarion have been asked to set out a notification protocol within 
this policy so that this can be agreed with the Local Authority.   It is appropriate for the 
Housing Association to do this as they know their processes best.  The Local 
Authority have already provided contact details to Clarion for vulnerable adults and 
children’s services as well as an La housing contact, so that emergency decants can 
be notified as soon as the need is identified. On 03/01/23 Clarion informed us that 
they have considered their areas for improvement and these are now with their legal 
representatives for consideration and sign off before being sent to the Coroner. 

3.  Additionally, senior management in the LA Housing department have contacted 

Bromley Federation of Housing Associations to request that a meeting is convened to 
discuss this topic with their members, to ensure that they have due regard to 
arrangements for notifying LBB of emergency decants where there is a vulnerable 
household member. 

7 

THIS RESPONSE HAS BEEN PREPARED BY 

The London Borough of Bromley’s Head of Allocations & Accommodation and  
Head of Service for Occupational Therapy 

  8  DATE OF RESPONSE 

04/01/2023 

2

South London Coroner’s Court 
2nd Floor, Davis House 
Robert Street 
Croydon 
CR0 1QQ 

5th January 2023 

Dear Sir, 

Response to Regulation 28 report arising in the inquest of Samuel Pearson 

I write in response on behalf of Clarion Housing Group to your Regulation 28 report dated 10 
November 2022 which is addressed to the London Borough of Bromley Council (LBB), Oxleas 
NHS Foundation Trust and Clarion Housing Group (CHG). 

I would firstly like to offer my condolences to Mr Pearson’s family on behalf of CHG. 

Background  
As you know CHG are a provider of social housing and were pleased to be able to provide 
Samuel with accommodation in the form of an Assured Lifetime tenancy from the Spring of 
2021. In the months following the move, CHG were liaising with the LBB’s occupational 
health team around the need for some further adaptations to the property.  

Whilst at a relatively early stage there was recognition that Samuel would need to move out 
for a short period in order for this work to be undertaken. As I understand it from the 
inquest, Samuel’s mental health at this time was relatively stable and he had been 
discharged from the caseload of the mental health team, which was provided by Oxleas NHS 
Foundation Trust. 

On 20 June 2021 matters were overtaken by a van that crashed into the front of Samuel’s 
property making it immediately uninhabitable. Information regarding this was received 
promptly from Samuel’s occupational therapist at LBB whose hope it was that some of the 
types of property that had been considered as part of the planned move could be available, 
noting he was residing with his mother at this point. It was quickly established with LBB that 
these properties (available through LBB) were not ready for occupation.  

This notwithstanding CHG instigated an urgent assessment of need with Samuel and his 
mum and through a separate and specialist property search agency, located properties 
capable of meeting his needs, which was primarily for wheelchair access.  
At the time of the accident CHG assessed Samuel’s needs with his mum and were not given 
to think (having asked a direct question) that any other agency or professional needed to be 
immediately involved at that stage, noting that as part of the process CHG keep matters 
under close review.  

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 As the inquest heard, the properties initially located were situated in South London 
approximately an hour away from his Bromley home and Samuel and his mum’s preference 
was to remain close to Bromley and familiar surroundings where possible. As such and 
following a further property search Clarion were able to locate wheelchair accessible hotel 
accommodation in Bromley which Samuel and his mum preferred. Clarion therefore took 
steps to arrange this, and Samuel moved in on 28 June 2021.  
Following the move our team took steps to check in with Samuel and his mum as to the 
suitability of the accommodation during the following week and were given no reason for 
concern. 

This emergency provision ran alongside an urgent structural review of the damaged 
property in which it was coming to be understood how long remedial work would take, 
against which Clarion could keep under review with Samuel his family and others concerned 
the suitability of the temporary arrangement. 

On 6 July 2021 CHG received an email from the LBB occupational therapist (who we 
understand had not at that point met with Samuel or his mother) querying the choice of 
accommodation, in response to which CHG took immediate steps to begin a process of 
review. Sadly, it was only a very short time later that Clarion came to be informed of 
Samuel’s death on that same day. 

Review 
Since the inquest CHG have been reviewing its alternative accommodation and related 
assessment process to see what more if anything can reasonably be done to improve the 
system. 

As part of the review and in line with our ongoing commitment to service improvement, 
CHG are considering how, if at all, good interagency working can be further embedded into 
the processes underpinning the provision of alternative accommodation in circumstances 
such as this.     

This review remains ongoing at present and is expected to complete by the 31st January 
2023. 

I hope this is of assistance and assurance that the concerns raised are being considered and, 
where the need for improvement is identified, I can give you my assurance that it will be 
implemented. 

Yours sincerely 

Director of Customer Services 
Clarion Housing Group

29 December 2022 

FAO:  HM Assistant Coroner Jonathan Landau 
South London Coroner’s Court 

Dear Mr Landau 

Oxleas NHS Foundation Trust 
Pinewood House 
Pinewood Place 
Dartford 
Kent  
DA2 7WG 

oxleas.nhs.uk 

Re: Regulation 28 Report to Prevent Future Deaths (PFD) Report following the inquest into 
the death of Mr Samuel Pearson  

Thank you for your correspondence received on 10 November 2022 containing a regulation 
28 report to Prevent Future Deaths (PFD) following the conclusion of the inquest into the 
death of Mr Samuel Pearson on 6 July 2021.  Firstly, I would like to offer sincere apologies to 
Mr Pearson’s family on behalf of both the ADAPT team and the Trust. 

This response is made on behalf of Oxleas NHS Foundation Trust regarding the concern you 
set out in the PFD report. The concern specifically highlighted for the Trust is: 

•  A referral was made by Mr Pearson’s GP to the ADAPT service but at the time there 
was a 2-3 backlog in screening referrals and the GP was not made aware of the 
capacity issues. A robust contingency plan would ensure that referrers are informed 
when services are not able to meet usual service expectations. 

At the inquest we confirmed that we had been reviewing our ADAPT Operational Policy, 
however, it had not concluded in terms of how we would inform referrers about service 
expectations. Our new policy is now complete, and it now clearly sets out the expectations of 
what information services users and the referrer will receive once the Team receive the 
referral in terms of waiting times. A copy of the new Operational Policy incorporating this new 
process is enclosed with this response. 

The ADAPT Pathway provides focused, therapeutic interventions to adults residing within the 
three Boroughs who require care and treatment for Anxiety, Depression, Affective disorders, 
Personality disorders & Trauma. 

An automated email will be generated and sent to the referrer:   

Thank you for your referral. Please note that we aim to screen all referrals within 5 working 
days of receipt. The referral will also be discussed at the team's Multi-Disciplinary Team  
meeting so the appropriate plan can be drawn for the service user. The service user and you as 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the referrer will receive a letter informing you of our current waiting times. If this referral is 
urgent and an urgent response is required, please contact the ADAPT duty worker (please 
insert the relevant team number here) who is the person who can support you with an 
escalation and or offer further advice. 

In terms of contingency planning when services are not able to meet usual service 
expectations, all teams have in place a Business Continuity Plan which describes actions that 
they are required to take in circumstances such as situations where there may not be 
sufficient staff to safely deliver a service. At times when it is required to enact the plans 
communication with relevant stakeholders (including GPs and patients) will take place and is 
overseen by the Senior Management Team and through the Trust’s Governance structures. 
There is a yearly audit review undertaken with each team to ensure the plans are fit for 
purpose.  

In conclusion, I am grateful for your report which has ensured that additional measures have 
been instituted so lessons are learned from the death of Mr Samuel Pearson. I hope I have 
addressed the concerns. 

Your sincerely 

Chief Executive 

Enc: ADAPT Operational Policy