Prevention of Future Deaths reports · 2024

Colin Waterhouse

Regulation 28 report to prevent future deaths, reference 2024-0248, written 7 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report7 May 2024
Reference2024-0248
DeceasedColin Waterhouse
CoronerAlison Mutch
Coroner areaManchester South
CategorySuicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 IS BEING SENT TO:  Secretary of State for Levelling 
Up, Housing and Communities 

1  CORONER 

I am Alison Mutch, HM Senior Coroner, for the coroner area of South 
Manchester 

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 12th  September 2023 I commenced an investigation into the death of 
Colin Waterhouse. The investigation concluded on the 2nd  April 2024 and 
the conclusion was one of suicide. The medical cause of death was 1a) 
Hanging. 

4  CIRCUMSTANCES OF THE DEATH 

Colin Waterhouse was diagnosed with pancreatic cancer and given 
indication that the average survival time was 8 - 10 months. Palliative 
treatment was offered. He was referred to cancer support services. He 
found his accommodation in social housing difficult and it impacted his 
mental health significantly whilst he was also struggling to deal with his 
cancer diagnosis. He became eligible to bid for alternative properties as a 
consequence of his health. He struggled to make bids and navigate the 
complex system. This was exacerbated by a shortage of social housing. 
On 11th September 2023 he was found suspended by a ligature 

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 

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 unless action is taken. In the circumstances it is my statutory duty to 
report to you. 

The MATTERS OF CONCERN are as follows.  – 
The inquest heard evidence that the social housing where Mr 
Waterhouse lived was such that it was impacted his overall health and 
wellbeing after his terminal cancer diagnosis. It was recognised that his 
housing was impacting his mental wellbeing but the support services 
available to him (as a palliative care patient) did not have the 
resources/capacity to assist him in moving to alternative accommodation 
for the last few months of his life. 
The evidence was that because he lived in social housing he had to bid 
for alternative accommodation. The bidding process was digital and he 
struggled to manage that. 
In addition even if he made a bid the chances of success were extremely 
slim given the huge demand for property. The inquest was told as an 
illustration that the Housing Association that he was a tenant of had 
35,000 properties but a waiting list of 17,000. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe you 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 2nd  July 2024. 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 and to the following 
Interested Persons namely 
family, who may find it useful or of interest. 

, on behalf of the 

I am also under a duty to send the Chief Coroner a copy of your 
response. 

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 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 

Alison Mutch 
HM Senior Coroner 

07.05.2024 

3

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Dluhc (PDF)
The Rt Hon Angela Rayner MP 

Secretary of State for Ministry of Housing, 
Communities & Local Government and Deputy Prime 
Minister 
2 Marsham Street  
London  
SW1P 4DF  

Your reference: 
Our reference: 

10 September 2024

Alison Mutch 
HM Senior Coroner 
Manchester South 

Dear Alison, 

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS: INQUEST INTO 
THE DEATH OF COLIN WATERHOUSE 

Thank you for your letter and  investigative report dated 7 May 2024 into the tragic death of Colin 
Waterhouse, which was made in accordance with  Paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  

I am grateful for your conduct of the inquest and bringing this case to my attention. 

Thank you also for granting an extension to the deadline for this response so that I could respond 
as  the  incumbent  Secretary  of  State  for  the  Ministry  of  Housing,  Communities  and  Local 
Government. I wish to express my sincere condolences to Mr Waterhouse’s family and friends.  

Providing safe, secure, affordable housing for those in need is of vital importance to this Government 
and we are committed to delivering a substantial increase in good quality social housing.  

This response will focus on the two key areas of concern which you identified in your report. Firstly, 
the bidding process for an allocation of social housing and secondly the availability of social housing. 

Matter of concern one: The bidding process  
“The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it 
impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that 
his  housing  was  impacting  his  mental  wellbeing  but  the  support  services  available  to  him  (as  a 
palliative  care  patient)  did  not  have  the  resources/capacity  to  assist  him  in  moving  to  alternative 
accommodation for the last few months of his life. The evidence was that because he lived in social 
housing  he  had  to  bid  for  alternative  accommodation.  The  bidding  process  was  digital  and  he 
struggled to manage that.” 

Social housing provision 
In the vast majority of cases social housing in England is provided by local authorities  or private 
registered  providers  (PRPs),  namely  Housing  Associations.  Many  PRPs  make  their  properties 
available to house tenants on local authority waiting lists under a ‘nomination’ arrangement with one 
or  more  local  authorities.  However,  in  some  instances,  PRPs  let  their  social  housing  directly  to 

 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 tenants (known as ‘direct lets’) without involvement of a local authority. In 2022/23, 45% of new lets 
in housing association stock were direct lets outside of the local authority allocations process.  

We  understand  that  Mr  Waterhouse  lived  in  housing  association  accommodation  provided  by 
Jigsaw. We are not aware if Mr Waterhouse’s housing was allocated under a nomination agreement 
or if it was a direct let. We are also not aware whether Mr Waterhouse’s need to move was brought 
to the local authority’s attention and if his difficulties accessing the bidding process were linked to 
the process operated by his local authority or  operated by Jigsaw. I have therefore set out below 
some factual details on the allocations system. 

Social housing allocations by local authorities 
The demand for social housing exceeds supply. To manage that supply fairly, local authorities must 
have an allocation scheme in place. Although not required by law, most local authorities operate a 
waiting list. Housing is allocated from the local authority’s own stock (where it has any) and also 
from accommodation available from housing associations where it has a nomination agreement in 
place. 

There  are  certain  groups  of  people  to  whom  local  authorities  must  give  reasonable  preference 
(priority) when allocating social housing. This includes people who need to move from their existing 
accommodation  (including  those  already  in  social  housing)  for  medical  or  welfare  reasons.  In 
addition, local authorities have discretion to give additional preference  i.e. an even higher priority, 
to persons who need to move for medical or welfare reasons and deemed in urgent housing need.   

By  law,  local  authorities  are  required  to  include  in  their  allocations  schemes  a  statement  of  the 
authority’s policy on offering a choice of accommodation or the opportunity for applicants to express 
preferences about the accommodation to be allocated to them. It is for local authorities to determine 
their policy on providing choice or the ability to express preferences.  

Housing association allocations 
As  set  out  earlier,  housing  associations  can  grant  tenancies  to  households  nominated  by  local 
housing  authorities  and  make  direct  lets.  Legislation  makes  it  clear  that  PRPs  have  a  duty  to 
cooperate with housing authorities – where the authority requests it - to such extent as is reasonable 
in  the  circumstances  in  offering  accommodation  to  people  with  priority  under  the  authority’s 

allocation scheme.  

The  Regulator  of  Social  Housing’s  Tenancy  Standard  also  states  that  all  registered  providers  of 
social housing must: 

•  allocate and let their homes in a fair and transparent way that takes the needs of tenants and 

prospective tenants into account;  

•  co-operate with local authorities’ strategic housing functions and assist local authorities to fulfil 

their duties to meet identified local housing need; and  

•  seek to allocate homes that are designated, designed, or adapted to meet specific needs in a 

way that is compatible with the purpose of the housing. 

As part of the regulatory framework, to which all registered providers of social housing are subject, 
there are outcomes  that social landlords must deliver to ensure the fair allocation and lettings of 

 
 
 
 
 
 
 
 
 homes. If they do not meet the outcomes set by these standards, the Regulator for Social Housing 
can choose to investigate and take action as necessary.  

Mutual Exchanges and Transfers 
I understand from the report that Mr Waterhouse had been allocated a property in social housing 
but wished to move to alternative accommodation, due to the impact on his wellbeing. Under current 
rules, existing tenants who wish to move properties must do so either through mutual exchange, or 
via  their  local  authority  transfer  list.  Local  housing  authorities  may  also  require  tenants  to  bid 
(express interest) for a property. Housing Association PRPs may have their own bidding process in 
place for this or rely on the one put in place by the local housing authority. 

Existing social tenants who are applying for a transfer with the local authority must be treated on the 
same basis as new applicants if they are considered to have reasonable preference (priority) for 
social housing. 

Accessibility of Social Housing bidding process 
Under  the  statutory  framework,  local  authorities  must  provide  any  assistance  necessary,  free  of 
charge, to enable people who would have difficulty to make an application. This is also reflected in 
social housing allocations statutory guidance which is issued to local housing authorities. 

In any event, local authorities and housing associations must adhere to the relevant provisions in 
the Equality Act 2010 to ensure that those who have protected characteristics and require support 
are not unlawfully discriminated against as part of their service delivery.  

Guidance also makes clear that local housing authorities and housing associations have a duty to 
share information where appropriate regarding safeguarding concerns, including for the prevention 
of  suicide.  We  are  not  aware  as  to  what,  if  any,  information  was  shared  with  the  local  housing 
authority in this case.  

Matter of concern two: Availability of accommodation 
“In  addition  even  if  he  made  a  bid  the  chances  of  success  were  extremely  slim  given  the  huge 
demand for property. The inquest was told as an illustration that the Housing Association that he 
was a tenant of had 35,000 properties but a waiting list of 17,000.” 

On 30 July, I set out our first steps in this Government’s plan to build the homes this country needs 

and to deliver on our commitment to the biggest growth in social and affordable housebuilding in a 
generation. We will set out details of future Government investment in social and affordable housing 
at the Spending Review, so that social housing providers can plan for the future and help deliver the 
biggest increase in affordable housebuilding in a generation. 

In the first instance, this Government’s aspiration is to ensure that, in the first full financial year of 

this Parliament (2025-26), the number of Social Rent homes is rising rather than falling. I have also 
set out a clear expectation that housing needs assessments must consider those requiring Social 
Rent homes, and that local authorities should specify their expectations on Social Rent delivery as 
part of broader affordable housing policies. This includes testing whether there is more that could 
be  done  to  support  developments  that  are  predominately  or  exclusively  affordable  tenures,  in 
particular Social Rent. 

 
 
 
 
 
 
 
 
 
 More immediately, we have increased the flexibilities on how councils can use their Right to Buy 
receipts. The Government has removed the caps on the percentage of replacements delivered as 
acquisitions and the percentage cost of a replacement home that can be funded using Right to Buy 
receipts, and councils have been given the ability to combine Right to Buy receipts with section 106 
contributions. These flexibilities will be in place for an initial 24 months, subject to review. 

To  further  empower  and  enable  councils  to  build  their  own  stock  of  affordable  homes,  I  also 
confirmed £450 million  investment  in  councils  across England  under the  third  round  of  the Local 
Authority  Housing  Fund.  This  will  create  over  2,000  affordable  homes  for  some  of  the  most 
vulnerable families in society, including families currently living in cramped and unsuitable bed and 
breakfasts. 

We  will  also  engage with  the  sector and  set  out more  detail  in the  autumn  on  our plans  to  raise 
standards on quality, and strengthen residents’ voices. We are committed to introducing Awaab’s 
Law  to  the  social  rented  sector,  and  will  set  out  more  detail  and  bring  forward  the  secondary 
legislation to implement this in due course. Further details on my announcement can be found at 
https://www.gov.uk/government/news/housing-targets-increased-to-get-britain-building-again. 

I  would  like  to  emphasise  this  Government’s  commitment  to  providing  safe,  secure,  affordable 
housing for those in need. Given the nature of this case, my officials have shared the details of your 
report with the Regulator for Social Housing who are considering the report's findings.  

Thank you for bringing the tragic death of Mr Waterhouse to my attention and, once again, I wish to 
express my sincere condolences to Mr Waterhouse’s family and friends. 

Yours sincerely, 

RT HON ANGELA RAYNER MP 
Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government

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