Prevention of Future Deaths reports · 2024
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 report | 7 May 2024 |
|---|---|
| Reference | 2024-0248 |
| Deceased | Colin Waterhouse |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
1
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.
2
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
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.
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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