Nicholas Cork

FAO Ian Potter 
HM Assistant Coroner 
Inner North London 
Camley Street 
London 
N1C 4PP 

12 April 2024 

Dear Sir 

Regulation 28 Prevention of Future Deaths report issued 11th January 2024, following 
the inquest into the death of Nicholas Cork 

We write to respond on behalf of Sapphire Independent Housing (‘Sapphire’) pursuant to the 
receipt  of  your  Regulation  28  report  dated  11th  January  2024,  identifying  concerns  arising 
from the death of Nicholas Cork. 

We would like to take the opportunity at the outset to extend our sincere condolences to the 
family and friends of Mr Cork. He was a well-liked and much-appreciated member of Conway 
House,  where he had been resident  since 2022; he has been sadly missed by support  staff 
and  other  residents.  The  company  has  taken  the  circumstances  of  his  death  extremely 
seriously, and has carefully considered the contents of the Regulation 28 report. 

The inquest proceedings 

Sapphire  was  not  legally  represented  at  the  hearing  before  you  nor  do  we  understand  that 
the  company  was  designated  an  Interested  Person.  We  have  taken  care,  therefore,  to 
understand  what  transpired  at  the  hearing  and  what  evidence  was  placed  before  you,  in 
order  to  fully  respond  to  the  contents  of  the  Regulation  28  report.  It  is  unfortunate  that  it 
appears  a  full  recording  of  the  hearing  is  not  available;  in  particular  there  is  reference  to 
material  being  placed  before  you  in  evidence  concerning  Conway  House,  that  does  not 
appear to have been captured on an audio tape or transcript1. 

1 It appears that the witness, 
, was asked during her evidence for a record of welfare checks and 
indicated  that  this  could  be  provided.  Her  evidence  was  suspended  while  this  material  was  obtained.  We 
understand that it was resumed at some point prior to the commencement of the police evidence but there is no 
record of this. 

30 Finsbury Circus, London  EC2M 7DT 
Tel 020 7 628 7576   Fax 0870 608 9390   DX 33856 Finsbury Square 
www.devonshires.com 

Devonshires and Devonshires Solicitors are the trading  names of  Devonshires Solicitors LLP,  registered  in England and  Wales at  the address 
above with company number OC397401. 
A list of members is open for inspection at our offices. This firm does not accept service by electronic mail or facsimile. 
This  Firm  is  authorised  and  regulated  by  the  Solicitors  Regulation  Authority  under  the  name  of  Devonshires  Solicitors  LLP  and  registration 
number 619881 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 We  understand  that  a  witness, 
,  who  is  not  a  Sapphire  employee  but  had 
worked at  Conway  House for  around  3  years  as  an agency  worker,  gave  evidence on oath 
regarding  the  checks  performed  on  Mr  Cork  prior  to  the  tragic  discovery  of  his  body  in  the 
morning of 22nd  May 2023. It also appears that 
, a manager at Conway House, 
who was present at the inquest hearing though not previously designated a witness, and not 
(it  appears)  sworn  in  as  such,  provided  some  information  on  an  ad  hoc  basis  as  to  the 
systems  and  processes  in  place  at  Conway  House.  There  had  been  no  prior  disclosure 
requests made of the company, but it appears some documentary material was located and 
provided during the course of the hearing, either by 
; this appears 
to  have included a digital  copy of the welfare check record spreadsheet  (‘the spreadsheet’), 
which  records  (for  each  resident  subject  to  regular  checking)  the  time  they  were  seen,  the 
person  completing  the  check  and  any  additional  comments.  Plainly,  there  was  more 
information  available  that  Sapphire  now  believes  would  have  assisted  you  and  perhaps 
allayed  some  of  your  concerns  about  the  procedures  in  place  at  Conway  House,  and  it  is 
regrettable that this was not before you at the hearing. 

With this in mind, our approach in this response is twofold; both to (where appropriate) clarify 
the systems and processes in place at the time of Mr Cork’s death as well as to identify what 
actions  have been taken  since  then  to  improve matters  and  guard  against  the  risk  of  future 
deaths arising. 

Independent investigation 

Following the death of  Mr  Cork,  and prior  to  the  commencement  of  the  inquest  before you, 
Sapphire undertook its own internal investigation into what had occurred. This culminated in 
a  post-death  review  meeting  on  28th  July  2023.  All  agencies  who  had  worked  with  Mr  Cork 
were  invited  to  the  meeting,  including  a  member  of  the  commissioning  team  from  Camden 
Council and any next of kin. Several Sapphire employees and at least one representative of 
the  Camden  commissioning  team  attended.  The  outcome  of  this  review  meeting  included 
recommended improvements  in  how  the process for  checking residents  operated,  review  of 
the weekend cover  arrangements  at  Conway  House and review  of  the handover  procedure 
between shifts. 

Sapphire  also  commissioned  an  independent  investigation  by  Homeless  Link  into  the 
circumstances of the death and any wider cultural and governance observations pertaining to 
Sapphire  and  Conway  House.  Homeless  Link  are  well-respected  experts  in  improving 
services  linked  to  supporting  people  experiencing  homelessness;  they  offer  training  and 
consultancy services to this end. Homeless Link carried out the review in early July 2023 and 
provided  a  report  to  the  company  in  August  2023,  making  a  number  of  recommendations. 
The  report  was  shared  with  the  Sapphire  Board  in  September  2023.  An  action  plan  and 
timetable  for  the  implementation  of  these  recommendations,  which  incorporated  those  that 
followed the internal review, was set. The action plan was shared with Camden Council and 
they  have  maintained  some  oversight  of  progress,  not  least  through  quarterly  review 
meetings  which  take  place  between  Sapphire  and  Camden.  As  may  be  expected,  many  of 
the  recommendations  mirror  the  concerns  expressed  in  the  Regulation  28  report  and 
therefore we address these below in the context of actions taken or proposed under each of 
the matters of concern identified by the report. 

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 It  is  of  note  that  the  Homeless  Link  report  concluded that  the  Conway  House service  has  a 
strong culture of care. 

Matters of concern 

The matters of concern raised in the Regulation 28 report are set out and addressed in turn 
below. 

1.  There was evidence that staff at Conway House were significantly concerned 
for Mr Cork’s welfare, which is why he was deemed as ‘at risk’. As a result of 
being ‘at risk’ I was told that welfare checks were required to be undertaken, at 
least every 24 hours. Such checks required a staff member to physically see 
and interact with Mr Cork or, in the alternative, to telephone him and speak to 
him.  Welfare  checks  were  then  required  to  be  recorded  on  a  spreadsheet. 
Despite this, I was told in evidence that welfare checks would only be recorded 
if the resident in question was actually ‘seen’ by the staff member undertaking 
the check; this raises the concern that there is disparity about what constitutes 
a welfare check and what will or will not be recorded. 

The  At  Risk  procedure  at  Conway  House  has  been  in  place  for  a  number  of  years  (last 
reviewed in July 2020), and Sapphire understands it is consistent with procedures in place in 
other,  similar,  supporting  housing  settings.  Sapphire  does  not  believe  that  any  external 
agency  has  ever  questioned  the  content  of  the  procedure;  it  is  known  to  Camden  Council 
who have not raised concerns. 

The procedure may properly be summarised as follows. All residents are reviewed on arrival 
as to their specific needs and vulnerabilities, and whether they should be included on the At 
Risk Register. If they are, the At Risk procedure requires welfare checks to be conducted on 
those  residents  once  every  24  hours.  A  welfare  check  may  include  physically  seeing  and 
interacting with a resident, or speaking to him/her via telephone. The mode of check does not 
affect  the  necessity  to  record  it  on  the  spreadsheet;  whether  conducted  in  person  or  via 
telephone,  the welfare check  ought  to be recorded.  Unless the resident  has  been seen and 
interacted  with,  or  spoken  to  on  the  telephone,  an  adequate  welfare  check  has  not  been 
completed. If the daytime shift workers have not been able to complete a welfare check, this 
negative  should  be  noted  on  the  spreadsheet  and  the  negative  welfare  check  passed  onto 
night staff at handover. If no welfare check is achieved by the night staff, the missing persons 
procedure will be triggered in the morning2. 

Sapphire considers that this policy, if understood and followed correctly, properly provides for 
the  welfare  checking  of  the  vulnerable  persons  within  its  care  and  includes  appropriate 
mechanisms  for  failed  safety  checks  to  result  in  an  escalation  of  checks  and,  if  necessary, 
the triggering of the missing persons procedure. 

2 This is set out in policy document ‘Missing Persons Produced – Supported’ approved in 2013, and last 
reviewed in 2016 

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 Notwithstanding  this,  Sapphire  has  reviewed  the  At  Risk  procedure  set  out  above 
subsequent  to  Mr  Cork’s  death.  This  review  was  completed  on 
January  2024.  The 
procedure was looked at in the round and it was decided that it remained fit for purpose but 
that  improvements  needed  to  be  made  in  relation  to  its  implementation  and  operation, 
including as to training, oversight and accountability. These are addressed below. 

1st

2.  I  heard evidence  that prior  to  Mr  Cork  being  found  unresponsive  in  his  room 
on 22 May 2023, the last recorded welfare check for Mr Cork was during the 
early shift of Saturday 20 May 2023. The concern here is that Mr Cork, despite 
being required to have welfare checks at least once every 24 hours, was not 
properly checked upon for between 36-48 hours prior to his death. 

3.  A  night  project  worker  at  Conway  House  told  me  in  evidence  that  they  had 
opened  Mr  Cork’s  door  at  about  20:35  on  Sunday  21  May  2023,  but  did  not 
enter  the  room  to  see  or  assess  Mr  Cork.  The  only  reason  for  opening  the 
door appears to have been the arrival of the ‘EMS team’ who were required to 
check that Mr Cork was at home for the purposes of conditions imposed by the 
criminal  justice  system.  Having  heard  what  they  believed  to  be  snoring,  the 
staff  member  closed  the  door  and  left.  This fact  was  verified  by  Metropolitan 
Police Officers who checked CCTV footage as part of their initial investigation 
following  Mr  Cork’s  death.  The  concern  here  is  that  staff  made  assumptions 
that  the  ‘snoring’  noise  was  coming  from  Cork’s  room  and  not  an  adjoining 
room, and that the noise was snoring, without investigating further. This was a 
missed opportunity to properly check on Mr Cork’s welfare, as required. 

Points  2 and 3 are, respectfully,  dealt  with together  as they raise the same issues as to the 
adequacy of the welfare checks performed in this case between 20th  and 22nd  May 2023. 

It is accepted that the At Risk procedure was not adequately followed by support staff in the 
days  prior  to  Mr  Cork’s  death,  and  that  this  was  not  identified  contemporaneously  by  any 
management checks. It is accepted that the check that was conducted on Mr Cork during the 
evening  on  21st  May  2023  was  not  an  adequate  welfare  check  because  it  did  not  involve 
interacting with him, merely hearing him snoring and assuming he was therefore sleeping. 

Sapphire  has  therefore  fully  recognised  the  need  for  improvement  in  how  the  At  Risk 
procedure  is  implemented,  followed  and  managed.  As  the  Homeless  Link  report  also 
emphasised, it should form the foundation of the interaction of the staff team daily. Sapphire 
has reset its priorities in this regard. 

In  particular,  the  handover  process  has  been  reviewed  to  place  further  emphasis  on  the  At 
Risk procedure. This review was completed on 8th  August 2023. There has, as a result, been 
an  increase  in  the  working  hours  of  night  shift  workers,  thereby  extending  the  handover 
period  between  shifts  to  ensure  an  appropriate  face  to  face  interaction  to  discuss  any 
incidents  that  have occurred.  There  is an expectation that  any  failed  welfare  checks,  or  any 
problems  with  the  At  Risk  procedure,  will  be  highlighted  at  this  handover.  There  is  a 

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 handover  template  that  must  be  completed  prior  to  every  shift  handover;  this  includes  a 
specific section for recording issues concerning At Risk register checks. 

Further training provision has also been (and continues to be) implemented in relation to the 
At Risk procedure with a view to offering staff an increased level of support and knowledge. 
Training  in  complex  needs,  dual  diagnosis  and  personality  disorder  was  delivered  by 
Homeless  Link  on  22nd  September  2023  for  all  resident-facing  colleagues.  A  workshop 
covering  welfare  checks  and  risk  management  was  attended  by  all  Conway  House  staff  in 
February  2024.  Following  a  Homeless  Link  recommendation  that  Sapphire  services  are 
reflective  of  psychologically  informed  environment  approaches,  as  these  environments 
naturally  reduce  the  levels  of  incidents  and  are  more  conducive  to  positive  residential 
operations, the Camden Commissioning team  are providing training in this area and regular 
refresher  courses to all staff  in  Pathways.  Training needs are now discussed as part  of  one 
to  one  supervision and appraisals  and  training needs  are  identified for  each staff  member’s 
development. 

Since  October  2023,  there  has  been  greater  focus  on  revisiting  the  guidance  derived  from 
policies  and  procedures  to  support  day  to  day  practice;  not  just  at  induction  but  on  a 
continuing  basis,  through  team  meetings,  team  away  days,  and  a  wider  organisational 
approach.  The  At  Risk  procedure,  while  well-established  as  a  precursor  to  the  Missing 
Persons  policy,  has  not  historically  been  set  out  fully  in  a  written  policy  document.  A 
standalone  policy  document  is  in  the  process  of  being  drafted  and  is  expected  to  be 
presented to the Sapphire Board in May, for wider publication in June 2024. All staff receive 
online  training  in  policies  and  procedures  with  periodic  refresher  training.  There  is  also  an 
easily accessible online hub where a policy library is available. 

Sapphire has recognised that there needs to be a greater level of management review of the 
At  Risk  procedure,  and  greater  accountability  for  proper  checks  being  carried  out.  The 
Homeless  Link  report  noted  that  if  the  completion  of  the  At  Risk  checks  was  a  process  for 
which  managers  were  forensically  held  to  account  by  the  Executive  Team  and  reviewed  at 
Board level, culturally the missing of checks would be far less likely to happen, whatever the 
chaotic dynamic of the service. This culture of accountability has been implemented through, 
for example, a housing operations team away day in April 2024, which focused on discussing 
Key  Performance  Indicators  (KPIs),  including  in  relation  to  the  operation  of  the  At  Risk 
procedure,  which  are  to  be  introduced  and  monitored  monthly  as  part  of  the  Operational 
Management  meeting.  Senior  management  performance  meetings  are  to  commence  from 
April 2024. Any service incidents are to be reported at Board level, along with any failures to 
meet KPIs. 

Sapphire  is  therefore confident  that  the risk of  staff  error  in the conduct of  welfare checking 
and the operation of the At Risk procedure as a whole should be considerably reduced, and 
that if errors occur, they are more likely to be identified at the time. 

4.  In  evidence,  I  was  taken  through  the  spreadsheet  that  is  used  to  record  all 
checks  and/or  welfare  checks  required  for  any  residents  of  Conway  House. 
The record system appears to have been a basic Microsoft Excel spreadsheet 
devised  by  staff.  I  was  told  that  the  computer  and/or  spreadsheet  often 
‘crashed’,  which  led  to  data  sometimes not being  able  to  be  recorded.  I  also 

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 observed  that  some  fields  of  the  spreadsheet  were  often  left  blank.  Staff 
undertaking  and  recording  checks  regularly  appeared  not  to  input  their 
name(s)  or  the  time  at  which  checks  were  undertaken.  I  was  also  told  that 
while there was some training on how to undertake and record welfare checks, 
this  was  not  needed  because  it  was  a  simple  task.  The  concern  here  is  that 
the  recording  system  for  welfare  checks  may  not  be  adequate  and  that  the 
approach  taken to  filling  in  the  data  required  on  the  spreadsheet varied  from 
one  staff  member to another,  which  may  also  indicate that  there  is  a  training 
need. 

At  the time of  May 2023,  the spreadsheet  used to record welfare checks was considered to 
be  adequate,  insofar  as  it  allowed  for  the timing of  the  check,  the  identification  of  who  had 
completed it  and  any  additional  comments  to  be  recorded.  It  is  recognised that  its  use  was 
dependent  on  the  computer  that  stores  it  being  functional,  but  technical  issues  were 
extremely  rare  and  there  was  a  manual  workaround  about  which  staff  were  fully  informed. 
Any manual records were promptly recorded on the digital spreadsheet. 

Serious  consideration has  been given to  an alternative method of  recording  welfare  checks 
but,  following  a  thorough  review,  it  has  been  decided  to  maintain  the  current  format,  with 
which  staff  are  familiar,  and  which  has  functionality  to  record  all  the  required  information 
relevant  to  welfare  checks.  The  additional  focus  on  training,  management  oversight  and 
accountability that has been a feature of revisions to the At Risk process as a whole, equally 
applies  to  the  record-keeping  of  the  welfare  checks  on  the  spreadsheet  and  should  ensure 
operational improvement. The spreadsheet is currently reviewed by a manager every Friday. 
Additionally,  a  recruitment  process  is  underway  for  a  new  administration  assistant  to  assist 
with  housing  management  tasks,  which  will  include  the  oversight  of  the  spreadsheet  with 
qualitative  checks  and  sample  testing.  The  recruitment  process  is  expected  to  complete  in 
April 2024, with employment to commence in May 2024. 

That the current format of the record is fit for purpose will be kept under review. Enquiries are 
ongoing  as  to  whether  the  record  of  welfare  checks  could  be  integrated  into  wider  support 
software  used  by  staff  on  the  Inform  system.  This  review  is  likely  to  continue  throughout 
2024. 

Sapphire is confident that the increased prioritisation on the recording of welfare checks will 
place that record front and centre of staff work objectives, with oral communication between 
different shift teams also of paramount importance alongside the written record. 

5.  I  was  told  in  evidence  that  the  same  spreadsheet  is  still  used  to  record  any 
checks and/or welfare checks required for residents. I was told that the issues 
identified with a lack of checks for Mr Cork were caused by the fact that there 
were a significant number of agency staff on duty and that Conway House no 
longer  uses  agency  staff.  However,  the  staff  member  that  opened  Mr  Cork’s 
door at 20:35 (without entering the room or seeing Mr Cork) on 21 May 2023 
and  subsequently  found  him  unresponsive  on  the  morning  of  22  May  2023 
was a substantive member of staff. 

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  was not a substantive member of staff but, it is accepted, had worked at Conway 
House as a member of agency staff for a prolonged period. Sapphire continue to use agency 
staff  at  Conway  House.  However,  there  have  been  material  improvements  in  how  this  is 
managed and how the processes to be followed are communicated; in particular a thorough 
written  contractor  induction  package  has  been  formulated,  which  focuses  both  on  the 
conduct of welfare checks and their recording. 

Of  the  three  staff  members  (two  permanent  members  of  staff,  one  agency  staff)  with 
particular  responsibility  for  conducting  welfare  checks  on  20th  and  21st  May  2023,  and 
therefore  most  accountable  for  the  failures  that  occurred,  the  agency  contractor  had  their 
contract  terminated.  The  two  permanent  members  of  staff  were  both  subject  to  disciplinary 
procedures  concerning the  failure  to  conduct  adequate  checks,  the  failure  to  record  this  on 
the  welfare  check  spreadsheet  and  the  failure  to  complete  an  adequate  handover  to  night 
staff in this regard. 

It has been recognised that the weekend is the lowest level of staffing at Conway House due 
to  the  nature  of  the  funding,  rota  and  management  working  pattern.  The  Homeless  Link 
report  suggested  that  consideration  be  given  to  whether  there  should  be  management 
checks  taking  place  at  these  times,  for  example,  the  organisational  on-call  system  could 
incorporate  a management  check  of  the  At  Risk  register  during  the  weekend with  a view  to 
tightening  the  safety  net  of  checks  so  that  they  are  not  missed.  A  shift  leader  position  has 
now been introduced for each shift, tasked (in part) with ensuring that the At Risk procedure 
has  been  complied  with  and  that  an  effective  handover  is  completed  with  the  next  shift. 
There  is  also  now  a  Monday  morning  meeting  between  managers  and  staff  in  order  to 
facilitate  a thorough handover  of  any issues that  have arisen over  the weekend;  there is  an 
expectation that this will include a focus on any issues with the At Risk procedure. 

Permanent  night  staff  have been recruited by Sapphire  (with a start  date of  the end of  April 
2024)  with  a  specific  job  description  that  incorporates  the  At  Risk  procedure,  which  should 
increase continuity of knowledge and experience across the staffing body. 

In  September  2023,  Sapphire  completed  a  review  of  working  shift  patterns  and  how  the 
removal of a ‘7 days in a row’ shift pattern and its replacement with a more balanced working 
pattern may mean staff are more refreshed and less prone to burnout (which could have lead 
to  an  increased  risk  of  missed  checks).  Smaller  more  frequent  working patterns  have  been 
implemented across the board. 

Discussions also remain ongoing with the London Borough of Camden as to the support and 
care  needs of  referrals  into  Conway  House,  along  with a review  of  the Pathway to consider 
where  the  most  vulnerable  and  those  with  the  most  complex  needs  are  most  appropriately 
housed. 

In conclusion 

We reiterate that the death of Mr Cork was a source of considerable sadness and concern to 
Sapphire.  The  company  has  made  focused  efforts  to  understand  the  circumstances  of  his 
death  and  to  make  improvements  to  the  operation  of  the  At  Risk  procedure  in  light  of  the 

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 failings that were identified internally, by an independent review and by you the Coroner. The 
company 
is  confident  that  the  improvements  that  have  been,  and  continue  to  be, 
implemented will meet the concerns expressed during the inquest into Mr Cork’s death, and 
guard against the risk of future deaths. We sincerely hope that this response is of assistance 
to you,  and would welcome the opportunity to provide any further  clarification or  information 
that you may require. 

Yours faithfully 

Devonshires Solicitors LLP 

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