Jacqueline Smith

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

Touching the death of Jacqueline Elizabeth Smith 

1 

THIS RESPONSE IS MADE ON BEHALF OF:  

London Borough of Hillingdon 

2 

REGULATION 28 REPORT RESPONSE: 

This  response  is  in  answer  to  the  report  made  to  the  London  Borough  of 
Hillingdon on 21 August 2023 by Mrs. Lydia Brown, the Acting Senior Coroner 
for West London, under paragraph 7 of Schedule 5 to the Coroners and Justice 
Act  2009  and  regulations  28  and  29  of  the  Coroners  (Investigations) 
Regulations 2013. 

3 

INVESTIGATION AND INQUEST: 

On 16 August 2022, the Coroner commenced investigation into the death of 
Mrs Jacqueline Elizabeth Smith. The investigation concluded at the end of the 
inquest, which took place on 10 August 2023. 

The conclusion of the inquest was suicide. 

The coroner concluded that the cause of death was: 
1a Respiratory depression 
1b 

 overdose, exacerbated by the concomitant use of 

.  

4 

CIRCUMSTANCES OF DEATH: 
[Quoted directly from the Coroner’s Report] 

Took her own life by an overdose of prescribed medication at home and died 
in Hillingdon Hospital on 12 August 2022. At the time, she was in poor physical 
health  and  experiencing  considerable  anxiety  as  she  was  trying,  with 
assistance  from  the  Council,  to  clear  her  home  of  numerous  hoarded 
possessions. She spoke with the single point of access (SPA) crisis telephone 
service during the evening of 10 August 2022 to ask for help, but no mental 
health assessment was performed, and she was not called back by the team 
as promised. Her neighbour requested a welfare check be performed the next 
day when she was found collapsed and taken to hospital.  

5 

CORONER’S CONCERNS: 

The matters of concern set out by the Coroner in her report are as follows: 
[Quoted directly from the Coroner’s Report] 

Page 1 of 8 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mrs  Smith  was  recognised  to  be  a  hoarder  and  her  council  property  was 
dangerously  full  of  items  blocking  all  access,  impeding  stair  access  and 
impacting on her ability to access the kitchen or bathroom. The gas supply had 
been cut off as she did not allow access for the annual inspection. 

Mrs Smith recognised she had a problem and asked the council for assistance. 
The  offered  solution  only  moved  some  of  her  belongings  into  a  local  "void" 
property that she did not have access to with no plan for how to resolve this 
temporary  situation,  creating  considerable  anxiety  and  stress  for  Mrs  Smith 
who then took her own life by overdosing with her prescribed medication.  

(1)  The inquest identified that there was insufficient staff training to deal 

with complex hoarder cases. 

(2)  Other  safety  assessments  such  as  a  fire  assessment  and/or 
environmental health assessment  were  not requested  despite  there 
being a clear need. 

(3)  The council "flow chart" was clearly not fit for purpose to assist staff in 
progressing  hoarder  support  and  assistance  and  was  focussed  on 
enforcement procedures rather than tenant support. The inquest was 
advised  that  the  council's  approach  was  not  enforcement,  but  their 
documentation did not support this. 

(4) 

It was entirely unclear what options were available (if any) when the 
first plan of assistance completely failed, leaving the vulnerable tenant 
excluded from her property with no forward plan. 

6 

RESPONSE TO CONCERNS (1)-(4) 
ACTION TAKEN / TO BE TAKEN & TIMESCALES: 

We are deeply saddened by the death of Mrs Jacqueline Smith and offer our 
sincere condolences to Mrs Smith’s family on behalf of the London Borough of 
Hillingdon.  

Concern (1): insufficient staff training to deal with complex hoarder cases. 

The  London  Borough  of  Hillingdon  holds  a  Housing  Management  Hoarding 
Panel, which specifically focuses on hoarding cases in Council properties. As 
a landlord, the London Borough of Hillingdon recognises the responsibilities it 
has to its vulnerable residents that may be affected by hoarding. 

The Terms of Reference for the Panel include the need to deliver training on 
hoarding  to  all  Officers  within  Housing  Management.  These  Terms  of 
Reference are at Appendix 1 of this response. Training aims to: 

•  Provide  Officers  with  information  and  practical  guidance  on  how  to 

effectively manage cases of hoarding. 

Page 2 of 8 

 
 
 
 
 
 
 
 
 
 
 •  Develop  a  closer  joint  approach  to  dealing  with  cases  of  hoarding, 
ensuring referrals are made to the Council’s Adult Social Care (ASC), 
Environmental  Health,  the  London  Fire  Brigade  (LFB),  the  resident’s 
General Practitioner (GP) and, where appropriate, a multi-agency risk 
assessment conference (MARAC). 

•  Document and provide guidance, support and sharing of best practice. 

•  Provide  a  framework  for  more  robust  casework  management  and 

monitoring. 

•  Develop an understanding of the psychological reasons why a person 

hoards.  

•  Ensure  that  staff  understand  when  a  case  presents  an  unacceptable 

risk and how they must respond.  

•  Highlight  when  a  case  is  a  safeguarding  concern  due  to  unwise 

decisions and lack of capacity.  

• 

Identify a range of support measures in the first instance and when to 
instigate  enforcement  measures  to  help  staff  in  determining  the  most 
appropriate and effective response.   

Although training has previously been delivered to Housing Management staff 
by Hoarding UK, further training will be delivered to all Officers within Housing 
Management  by  the  end  of  November  2023  as  part  of  mandatory  annual 
refresher training across the Service.  

Concern  (2):  Other  safety  assessments  such  as  a  fire  assessment  and/or 
environmental  health  assessment  were  not  requested  despite  their  being  a 
clear need. 

A series of flow charts has previously been submitted to the Coroner as part of 
the London Borough of Hillingdon’s report for the inquest. 

The London Borough of Hillingdon has considered the concerns the Coroner 
has raised and has reviewed the flow charts and amalgamated them into one 
flow chart for all Officers. This action was completed at the end of September 
2023. This single flow chart now ensures that all Officers are prompted to make 
referrals  to  the  LFB  and  ASC  as  well  as  Environmental  Health  and  the 
resident’s GP where appropriate, and this step becomes protocol for all cases 
of hoarding in management.  

The  London  Borough of  Hillingdon  is  keenly  aware of  the fact that  hoarding 
can pose a range of health and safety hazards and the need to assess these 
formally and mitigate presenting risks.  

The  Service  is  committed  to  a  multi-agency  approach  bringing  together 
different  skills,  perspectives  and  resources  which  support  the  Tenancy 

Page 3 of 8 

 
 
 
 
 
 
 Management  Officer  role.  Cases  can  be  referred  to  the  daily  High  Risk 
meetings, MARAC and ASC.  

Please see Appendix 2 for the updated flow chart. 

Concern (3): The council "flow chart" was clearly not fit for purpose to assist 
staff  in  progressing  hoarder  support  and  assistance  and  was  focussed  on 
enforcement procedures rather than tenant support. The inquest was advised 
that the council's approach was not enforcement, but their documentation did 
not support this. 

In  the  London  Borough  of  Hillingdon’s  report  previously  submitted  to  the 
coroner for the inquest, a series of four flow charts were appended, each with 
a different purpose. 

As set out above in response to item (2) of the Coroner’s concerns, the London 
Borough of Hillingdon has reviewed the flow charts and amalgamated them to 
create one flow chart and removed reference to enforcement given that it is 
rarely  an  option  when  dealing  with  vulnerable  residents  where  a  range  of 
circumstances may have contributed to hoarding behaviour.  This action was 
completed at the end of September 2023. 

The revised flow chart will ensure that there is a more consistent approach by 
Officers  when  dealing  with  cases  of  hoarding.  The  London  Borough  of 
Hillingdon is committed to supporting its tenants to maintain their tenancies as 
far as possible and will act in the best interests of the resident.  

The London Borough of Hillingdon also recognises that there is a need to be 
flexible as each case is unique. The flow chart serves primarily as a guide / 
base for Housing Management staff. 

Enforcement  action  and  court  orders  are  pursued  only  in  exceptional 
circumstances  –  for  example,  where  enforcement  is  warranted  due  to  the 
tenant hoarding for commercial gain in breach of their tenancy agreement.  

The flow chart addresses the concerns raised by the Coroner by giving a clear 
focus to staff on the detection / suspicion of someone hoarding, checking their 
status with other partners / professionals, establishing the severity via a risk 
assessment,  and  then  referring  on  for  a  capacity  assessment  to  ASC  / 
enquiring about health before an action plan is developed. Within this process, 
there  is  clear  reference  to  assessing  presenting  hazards  and  mitigating 
presenting  risks  via  appropriate  referrals. The  flow chart will  form  part of  an 
Operational  Guidance  Note  for  staff  which  will  provide  further  clarity  on  key 
stages  of  casework  progression  such  as  flagging  hoarding  cases  in 
management  by  the  Panel  on  the  Housing  Management  data  base  (NEC 
Software Solutions) and referencing the case on the tenancy management file 
within  Civica  workflow  to  ensure  any  staff  member  working  on  the  same 
tenancy  is  aware  of  the  vulnerability  and  plan  associated  with  live  hoarding 
casework. This will also support management oversight of live casework. 

Page 4 of 8 

 
 
 
 
 
 
 
 
 
 
 The updated Operational Guidance Note for staff will form a key feature of the 
mandatory training for Housing Management staff in November 2023. 

Concern (4): It was entirely unclear what options were available (if any) when 
the  first  plan  of  assistance  completely  failed,  leaving  the  vulnerable  tenant 
excluded from her property with no forward plan 

Hillingdon  Council  aims  to  facilitate  positive  and  sustainable  outcomes  for 
residents who are the subject of any form of tenancy intervention casework, 
including  hoarding  behaviours  and  self-neglect.  In  part,  this  is  achieved  by 
involving them in the process of managing their behaviour at all key stages. 
The Council is committed to promoting choice and control to an individual over 
how they can best be supported. Residents can change their minds or other 
contributory  factors  may  require  changes  to  the  plan. This  approach  will  be 
fully reflected in the updated Operational Guidance for staff. 

Several  options  were  presented  to  Mrs  Smith  and  she  was  given  time  to 
consider each one. The first plan was to use garages on the same estate that 
were rented by a resident that had recently passed way. It soon became clear 
that  it  would  be  some  time  before  these  garages  would  become  available. 
Specialist  lifting  equipment  would  need  to  be  brought  in  to  remove  heavy 
engines which were being stored in the garages.  

The second option was to secure any garages nearby, but unfortunately none 
were forthcoming. 

A third option was presented to Mrs Smith relating to use of a one-bedroom 
property nearby in a sheltered scheme. The plan was to allow her a month to 
deal with her belongings in her own home whilst staying in the sheltered flat. 
However,  Mrs Smith  felt  anxious about  leaving  her  possessions  and  did  not 
view the property, so the option did not progress further.  

The fourth option was to clear the hallway and staircase and place items in a 
void flat in the same building, which was just opposite her own property. Once 
better access was secured, it would be possible to clear the rooms on the upper 
floors creating space for the return of Mrs Smith’s possessions from the void 
property. However, nearer the time of the decluttering, Mrs Smith expressed 
that she only wanted the clearance to be done in the kitchen and hallway. This 
prevented a room from being cleared and made available for the return of items 
that had been stored in the void property. 

In summary terms, the plan and options put forward continued to evolve over 
the episode of support. The need to keep plans under review and bring forward 
new options as part of a tailored approach will be fully reflected in the updated 
Operational Guidance for staff. 

After  the  declutter  for  Mrs  Smith,  the  Welfare  Reform  &  Tenancy  Support 
Manager arranged a follow-up visit before she was due to go on annual leave. 
Unfortunately, Mrs Smith cancelled  this appointment as she was  unwell and 

Page 5 of 8 

 
 
 
 
 
 
 
 
 
 the Welfare Reform & Tenancy Support Manager did not see her before she 
went on leave.  

The  London  Borough  of  Hillingdon  recognises  the  importance  of  aftercare 
following the decluttering of a home.  The Welfare Reform & Tenancy Support 
Manager was the Lead Officer dealing with the case. She was due to go on 
leave in the aftercare period and it is recognised that a better handover should 
have  taken  place  before  she  commenced  her  period  of  annual  leave.  It  is 
standard  practice  in  the  London  Borough  of  Hillingdon  for  every  Officer  to 
complete  a  handover  to  their  manager  just  before  they  go  on  annual  leave.  
With immediate effect, the London Borough of Hillingdon has made sure that 
this  standard  practice  is  extended  to  include  handovers  by  managers  who 
themselves  carry  a  caseload.  Handover  arrangements  generally  will  be 
specifically  covered  in  the  Operational  Guidance  Note  for  staff  and  covered 
during the training for all Housing Management staff in November 2023.  

It is accepted that leaving Mrs Smith’s possessions in the void property caused 
her distress and, in future, the London Borough of Hillingdon will ensure that 
suitable storage is arranged at the outset of the declutter and referenced in the 
tailored action plan and Operational Guidance Note.  

7 

DATE OF RESPONSE: 

12 October 2023 

8 

THIS RESPONSE WAS PREPARED BY: 

Welfare Reform & Tenancy Support Manager, London Borough of Hillingdon 

AND APPROVED BY: 

Head of Housing Management, London Borough of Hillingdon 

Corporate Director of Resources, London Borough of Hillingdon 

Page 6 of 8 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 APPENDIX 1 

Housing Management Hoarding Panel 

Terms of Reference 

Purpose 

The Housing Management Hoarding Panel forms part of the framework to support Hillingdon 
Council tenants that are known to hoard.  

The panel will consider hoarding cases that affect Hillingdon Council tenants; 

•  To document all hoarding cases and ensure appropriate support is offered to residents 

that engage with the service. 

•  To  ensure  a  co-ordinated  response  to  hoarding  cases  by  departments  in  Housing 

Management and internal and external partners.  

•  Review Hoarding cases regularly and ensure actions agreed have been completed by 

relevant officers.  

•  Review the resident’s housing need and provide support where appropriate to move 

to suitable accommodation ie Downsize/Sheltered/TA 

•  Make a Safeguarding Referral where appropriate. 
•  Refer complex cases to MARAC and wherever possible avoid enforcement action 
•  Ensure all officers within Directorate of Place receive training to better recognise and 

support residents that hoard. 

•  Ensure cases where there is a Fire/Environmental Risk that these are shared with LFB 

and EH.  

Membership/Representative 

Tenancy Management Team  

Housing Management Services Team  

Welfare Reform & Tenancy Support Team 

Sheltered Housing Team Leader 

Adult Social Care representative  

Repairs and Gas Compliance – optional 

LFB – Fire Service  

Referrals  

The  Hoarding  Panel  Referral 
housingsupportworkerteam@hillingdon.gov.uk 

form 

to  be 

completed  and 

sent 

to 

the 

Referrals should be submitted 15 days prior to the Panel meeting. All referrals will be reviewed 
to ensure it meets the criteria for the panel.  

Meetings 

Chair  WRTS  Manager  and  minutes  to  be  circulated.  Meetings  to  be  held  quarterly.  Via 
Microsoft Teams.  

Hoarders spreadsheet 

Owned by WRTS and shared with relevant teams. 

Page 7 of 8 

 
 
 APPENDIX 2 

Housing Management Hoarding Process 

Detection/suspicion of 
hoarding case 

TMO open case on 
residents Civica file 

Case added to HM 
Hoarding 
spreadsheet / NEC 

Check status with other 
agencies, assess 
severity, risk assess 

HM Panel to 
review cases 
quarterly 

Non-engagement. Case to be 
allocated WRTS Officer – joint 
work with TMO 

Resident willing to 
engage 

Not willing to accept 
help from WRTS/TM  

Resident lacks mental 
capacity  

Refer to High Risk Panel  

Refer to Adult Social 
Care for capacity 
assessment, LFB, EH 
and GP 

Agree Action Plan, 
Assess Housing/Care 
Needs  

Organise declutter, 
arrange any repairs 

Follow up home 
visit, monitor every 
4 to 6 weeks 

Action Plan 
completed. Agree 
case closure with 
manager 

Refer to MARAC and HM 
Hoarding Panel, 
Environmental Health 

Implement 
recommendations from 
MARAC. To be 
monitored by Hoarding 
Panel 

Page 8 of 8