Sam Taylor

Date:  21 August 2923 

Mr M Bricknell  
HM Senior Coroner - Herefordshire 
Town Hall 
St Owens Street 
HEREFORD 
HR1 2PJ  

Dear Mr Bricknell   

. 

SAM MALCOLM TAYLOR 

I write in response to the Regulation 28 report to Prevent Future Deaths dated 30 June 2023. 

Whilst I note that you have raised a number of concerns, which I have addressed separately below, 
I can offer my assurances that owing to a full review of this service that has recently taken place, 
which I must add took place not as a direct result of Mr Taylor’s sad death, substantial changes 
have been made to the structure, processes and practice within the service.  These steps have 
been taken to ensure that such an incident should never happen again. 

1) 

A  prevention  duty  was  owed  to  the  deceased  and  due  to  Herefordshire  Council 
communication process failure, contact was not made with him or those with whom 
he had approved contacts prior to his death. 

When  a  local  authority  has  reason  to  believe  that  a  person  might  be  threatened  with 
homelessness, it must accept a homeless application and make inquiries into what duties it 
might owe them.  

Following Mr Taylor’s initial contact with Herefordshire Council on 6 July 2022, and based 
on what information was known to the council and shared by Mr Taylor, a Prevention duty 
was  owed  as  Mr  Taylor  was  at  risk  of  becoming  homeless.  He  was  not,  at  the  point  of 
contact, homeless.  

Whilst it is accepted that a Prevention Duty was owed to Mr Taylor, it should be clarified that 
this  duty  under  s.195(1)  Housing  Act  1996,  as  substituted  by  s.4(2)  Homelessness 
Reduction Act 2017, exists to help find a solution to the individual’s housing situation. This 
includes taking all reasonable and practicable steps to prevent the individual from becoming 
homeless, assisting them to remain in the current accommodation or indeed helping them 
find a new place to live. 

This duty continues for 56 days or ends sooner if circumstances change. If, during that 56 
days,  all  efforts  result  in  no  change  and  cannot  prevent  someone  from  being  made 
homeless, a Relief Duty then becomes owed which provides a duty for the Local Authority 
to seek suitable accommodation.  

In Mr Taylor’s case, a Prevention duty was owed to him because at the time of his contact 
with the council, he was at risk of being made homeless, having told the duty officer that he 
was required to leave his accommodation on 11 July 2022.  As a result of this conversation 
on  6  July  2022,  the  duty  officer  entered his case  into  the  council’s  CRM  system  and his 
application  for  housing  was  also  opened  on  the  Home  Point  system.  However,  as 

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 acknowledged, his case was not progressed in a timely manner within the system and his 
case was not duly actioned and allocated. Had his case been triaged correctly, it would have 
been  allocated  to  an  officer,  who  would  have  taken  practical  and  all reasonable steps to 
prevent Mr Taylor from being homeless. This could have included speaking with his landlady 
and attempting to find  a  solution that  would  have allowed  him  to  remain. If  all  steps  had 
failed, it is likely a Relief duty would then become owed.  

A  fundamental  review  of  the  Council’s  housing  responsibilities,  services,  resources  and 
management was instigated by the Corporate Director, Community Wellbeing in January 
2023 and led by an independent investigator.  This review was undertaken due to concerns 
about the structure of housing being split between functions within the directorate and on 
the back of concerns expressed by the workforce.  

The review concluded at the end of March 2023 and made the following recommendations: 

1.  A  new  management  and  staffing  structure  is  proposed,  bringing  together  all  specific 
housing  services  under  a  single  management  team,  led  by  a  new  Head  of  Housing 
reporting directly to the Corporate Director. 

2.  A  new  overall  approach  to  housing  services  design  and  delivery  is  proposed, 
incorporating strategic objectives, principles, values, service development themes and 
a more comprehensive performance reporting regime.  

3.  A series of key priorities is identified for service improvement and development. These 
range from the housing front door and assessment, through the housing register and 
various forms of homeless prevention and intervention to accommodation strategy and 
capital housing development projects. 

4.  A significant overhaul of systems, procedures and operating practices is required. 

5.  A series of management practice improvements is recommended in relation to training, 
recruitment,  overtime,  staff  communications,  supervision  and  working  practices,  in 
promotion of a positive and effective organisational culture and best use of resources.  

6.  There  are  proposals  for  sustaining  and  enhancing  partnership  and  collaborative 
arrangements  including  strategic,  development  and  operational  forums  and  a  re-
constituted Housing Board. 

These recommendations have led to the development of a comprehensive implementation 
plan and in terms of progress to date against the plan, I can confirm that: 

  The  new  structure  is  in  place  which  brings  together  all  specific  housing  services 
under a newly created post of Head of Housing.  This post is being delivered through 
an acting up arrangement by an existing very experienced senior manager to deliver 
the immediate improvements identified through the review.  Permanent recruitment 
to the post will take place by the end of December. 

  An experienced interim service manager has been in post since April 2023 and is 
leading the service improvement and development work which has already delivered 
strengthened  processes,  from  first  point  of  contact  through  to  decision  making, 
reviewed housing procedures to ensure they align with the Homelessness Reduction 
Act and is providing ongoing comprehensive management guidance and support to 
front  line  officers.   Additional  experienced  interim  capacity  has  also  been  brought 
into the service at the front line to support the embedding of the changes. 

   The overhaul of systems, procedures and operating practices is in progress and is 
expected to be fully delivered by October 2023, alongside a comprehensive training 
programme for officers.   

The  wider  recommendations  in  relation  to  partnership  working  will  roll  out  from  January 
2024.  This will specifically include working with health colleagues in relation to ensuring 
that relevant information is shared to feed into any decision making processes. 

I can confirm that the Corporate Director reviews progress on a weekly basis with the Head 
of Service and Service Manager. 

2) 

Evidence  suggests  that  in  reality  Mr  Taylor  would  have  met  the  threshold  for 
vulnerability  set  out  in  the  Housing  Act  1996  but  the  failure  to  progress  the 
application resulted in this never being established.  

At  the  point  at  which  Mr  Taylor  contacted  the  service,  he  was  not  homeless  in  line  with 
relevant  legislation  and  it  was  not  anticipated  that  he  would  be  homeless  until  after  the 
weekend; hence he was owed a Prevention duty at the time of contact with the service. He 
was made aware that should his circumstances change, then a Relief duty would be owed.  

Following his conversation with the duty officer on 6th July 2022, Mr Taylor’s application was 
commenced. He was set up on the Home Point system to enable him to register for social 
housing.  We  are  aware  that  he  subsequently  accessed  the  system  that  evening  (as 
evidenced  by  case  log)  to  commence  his  application  but  had  not  completed  the  online 
application as was required to submit further documentation.   

As noted above, it is accepted that his case was not actively progressed in a timely manner 
through the internal triage system which would have prompted officers to have attempted 
to engage with him at an earlier stage. His case was left without being progressed which 
meant that no officer had oversight of his case. Once his case was triaged on 26th July 2022 
(albeit  20  days  after  his  initial  approach  to  the  council)  and  then  allocated  to  a  Housing 
Solutions officer on 3rd August 2022, officers then attempted to make contact. However, 
sadly, this was all too late as Mr Taylor passed away on/or prior to 17th July 2022.  

As Mr Taylor was not homeless at the initial point of contact and was owed a Prevention 
Duty, the homeless vulnerability tests were not carried out at the initial interview.  The need 
to carry out such a test does not apply until an individual is owed a Relief duty owing to them 
being homeless, eligible in priority need and the Local Authority is considering whether it 
has a duty to secure accommodation for the applicant.  

Subsequent  events  and  additional  information  which  was  unknown  to  the  Council  at  the 
time of Mr Taylor’s approach, has since suggested that he was more vulnerable than was 
first understood. This appears to be in part owing to his admission into hospital on 7 July 
2022.  The details and the reason for his admission to hospital, which happened after his 
initial approach to the council, were not subsequently shared with the Council.  

The implementation plan referred to in point 1 above includes ensuring our processes are 
robust  and  working  more  proactively  with  partners,  particularly  around  duty  to  refer 
obligations.  Had Mr Taylor’s case been progressed through the initial triage process at an 
earlier stage, and the service had become aware of his admission to hospital, it is likely that 
his case would have been duly reviewed and consideration given to the potential of a Relief 
Duty, which would have formally prompted a vulnerability test to have been undertaken.  

 
 3) 

A system for identifying process failure should be in place & effective  

Herefordshire Council can confirm that a system for identifying any process failure is now 
in place and operating.  The system covers: 

  Regular  supervision  of  individual  officers  by  their  line  managers  which  covers 

caseload reviews. 

  Daily  management  oversight  of  the  CRM  system,  specifically  focused  on  those 

cases in triage. 

  Weekly  reviews  of  each  case  at  different  stages  of  the  process  by  the  service 
managers with teams leaders, to ensure that they are being progressed in a timely 
manner. 

A programme of case auditing is also being developed in line with the directorate’s overall 
quality assurance framework which will roll out from October 2023. 

I trust that this response satisfactorily addresses the concerns raised in your letter but please do 
not hesitate to get in touch if further clarity on any point is required. 

Yours sincerely 

CHIEF EXECUTIVE