Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0424, written 31 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2023 |
|---|---|
| Reference | 2023-0424 |
| Deceased | Eric Huber |
| Coroner | Philip Spinney |
| Coroner area | Exeter and Greater Devon |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 31 OCTOBER 2023 IS BEING SENT TO:
Chief Executive – Devon County Council
1 CORONER
I am Philip SPINNEY, HM Senior Coroner, for the coroner area of Exeter and
Greater Devon.
2 CORONER’S LEGAL POWERS
I 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.
3
INVESTIGATION and INQUEST
On 15 April 2021 an investigation was commenced into the death of Eric
Sebastian Huber. The investigation concluded at the end of the inquest held on
10 October 2023. The conclusion of the inquest was as follows:
Eric Sebastian Huber was known to suffer with his mental health and was
considered to be vulnerable. On 1 April 2021 Mr Huber was discovered
deceased hanging
to self-inflicted suspension
. He died due
Eric Sebastian Huber died as a consequence of his own actions.
4 CIRCUMSTANCES OF THE DEATH
Mr Huber had a long history of drug and alcohol use dating back to 2005. – he
also had a long history of depression and anxiety. He had been managed
intermittently by the community mental health services.
Mr Huber was considered vulnerable and at risk of exploitation and harm from
others – he was known to the safeguarding team at Devon County Council
(DCC) and the safeguarding team at Devon and Cornwall Police.
His vulnerability was felt to be due to alcohol, chronic mental health problems
general self-neglect and to his ongoing misuse of drugs and risk of “cuckooing”
from convicted drug dealers.
In October 2019 a safeguarding enquiry was commenced and allocated to a
case worker at DCC to follow up with a visit to establish their views and risks
and discuss with the police. The case worker spoke with police officer who had
seen Mr Huber that day – the officer reported that Mr Huber was fine, he was
attending AA meetings regularly and coping much better – the case worker did
not follow up directly with Mr Huber and did not assess Mr Huber.
1
In September 2020 there was a further safeguarding concern raised to DCC by
the police as his flat was being used to sell drugs by two individuals staying
there – an activity known as cuckooing. The police requested a review of Mr
Huber’s care and support needs.
On 13 October 2020 this was allocated to the same caseworker as previously.
On 18 October 2020 Further concerns were raised with DCC around 2
individuals intimidating Mr Huber.
There is no written record in the DCC care first record system of action taken by
the case worker in response to these concerns.
From the records it appears that there is no evidence of a Care Act assessment,
multi-agency discussion meeting or consideration or Mr Huber’s situation and
how to manage the risk from drug dealers at this stage.
On 24 November 2020 Mr Huber himself called the DCC Adult Social Care
Direct via its call centre to ask for support – there is no record of this message
being followed up by the team manager or the social worker.
On 3 December 2020 a friend of Mr Huber rang DCC Adult Social Care Direct to
raise concerns over cuckooing and bullying of Mr Huber and that he was
struggling to cope.
The case worker called Mr Huber on 7 December 2020 and discussed help with
his drug and alcohol use and enabler assist to help with household matters – the
case worker noted that he would contact the police for an update. There is no
record of a call to the police.
On 8 December 2020 the safeguarding enquiry was closed with the outcome
that the immediate risks were adequately addressed and that it was a
proportionate response to reallocate for a full assessment of needs.
There is no record of that full assessment taking place.
On 15 January 2021 a police report was received by Devon Adult Social Care
Direct call-centre there are no records of any contacts or discussions arising
from this police contact.
The case was closed on 3 March 2021 – at this time there had been no
assessment of his needs.
5 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:
(1) The evidence shows that there were opportunities to engage with Mr
Huber and fully assess his risk and needs, these were not taken; in
addition, multi-agency and multi-disciplinary discussions to consider Mr
Huber’s situation and how organisations could work together to address
the concerns and risks were not conducted.
2
6 ACTION SHOULD BE TAKEN
(1) Consideration should be given to reviewing the processes of DCC
Adult Social Care to review how referrals are triaged, allocated and
actioned and how outcomes are recorded, monitored and reviewed.
In my opinion action should be taken to prevent future deaths and I believe you
and your organisation have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 29th December 2023 I, 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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner
I 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.
9 SIGNED:
Mr Philip C Spinney
HM Senior Coroner
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