Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0178, written 3 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Apr 2025 |
|---|---|
| Reference | 2025-0178 |
| Deceased | Loraine Cheesman |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | Product related deaths · Mental Health related deaths |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 1 CORONER I am Crispin OLIVER, Senior Assistant Coroner for the coroner area of County Durham and Darlington 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 26/05/2023 14:31an investigation was commenced into the death of Loraine Michelle CHEESMAN 12/06/1968 00:00:00. The investigation concluded at the end of the inquest on 03/04/2025 10:18. The conclusion of the inquest was that Died at Darlington, on 13 May 2023 as a consequence of a fire at the property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire.. 4 CIRCUMSTANCES OF THE DEATH Died at property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire. , Darlington, on 13 May 2023 as a consequence of a fire at the 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder: “This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self- neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.” During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes Regulation 28 – After Inquest Document Template Updated 30/07/2021 a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders. So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 May 29, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Darlington Safeguarding Partnerships Darlington Adult Social Care & Housing Services Careline Homecare who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 03/04/2025 Crispin OLIVER Senior Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Our ref:
HM Coroner Crispin Oliver
Senior Assistant Coroner for County Durham and Darlington
H.M. Coroners Office
P.O. Box 274
Stanley
County Durham
DH8 1HG
By email:
Dear Mr Oliver,
Minister of State for Care
39 Victoria Street
London
SW1H 0EU
29 May 2025
Thank you for the Regulation 28 report of 3rd April 2025, sent to the Department of Health
and Social Care, about the death of Ms Loraine Michelle Cheesman. I am replying as the
Minister with responsibility for adult social care.
Firstly, I would like to say how saddened I was to read of the circumstances of Ms
Cheesman’s death. I offer my sincere condolences to her family and loved ones. The
circumstances your report describes are concerning and I am grateful to you for bringing
these matters to my attention.
Your report quoted from the Care and Support Statutory (CASS) Guidance in relation to Self
Neglect and Hoarding Disorder. You noted professionals’ difficulty parsing the guidance’s
phrase “there may come a point”, referring to the point when an adult’s self-neglect means
they are no longer able to protect themselves by controlling their own behaviour.
In response, you recommended that DHSC provide guidance on:
a)
b)
how to incorporate consideration of Executive Dysfunction into the assessment of
mental capacity; and
how professionals should ascertain when the ‘trigger point’ for intervention is
reached in cases where hoarding disorder and/or executive dysfunction play a
role.
While you may already be familiar with the following points, I would like to set them out
clearly here as this is a particularly complex area:
• Lack of mental capacity is not the same as executive dysfunction – a person may
have mental capacity even if they lack ‘executive capacity’.
• Executive functioning problems can, however, lead to mental incapacity – particularly
an inability to use and weigh up the relevant information.
Inability to protect oneself – for section 42 Care Act purposes – is not the same as
lacking capacity to make a relevant decision. It is potentially wider.
•
• The courts have emphasised that, when assessing capacity in such cases, it is vital
to refer to evidence beyond the interview – including having a ‘performative’ aspect
to the capacity assessment.
I appreciate that professionals would welcome further guidance on this complex topic – they
may wish to consult the 2018 NICE guidance on decision-making and mental capacity:
Decision-making and mental capacity. This contains information on executive dysfunction.
It should be noted that professionals are expected to keep up to date with caselaw as well
as guidance. They may wish to explore recent judgments from the Court of Protection which
have addressed executive functioning, and how capacity should be assessed in such cases.
The following cases are relevant:
• Calderdale Metropolitan Borough Council v LS & Anor [2025] EWCOP 10 (T3) (13
March 2025)
• A Local Authority v AW [2020] EWCOP 24 (20 May 2020)
• A Local Authority v ZX [2024] EWCOP 30 (T2) (06 June 2024)
The Department will continue to disseminate such guidance and caselaw through its
partners and networks.
I hope this response is helpful. Thank you for bringing your concern to my attention.
Yours sincerely,
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