Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0259, written 28 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 May 2025 |
|---|---|
| Reference | 2025-0259 |
| Deceased | Callum Hargreaves |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and Isles of Scilly |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) · 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Secretary of State for Housing, Communities and Local Government 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 22 May 2025, I concluded the inquest into the death of Callum James Hargreaves who was found deceased on 20/1/24 at the age of 32. I recorded the cause of death as 1a) Multiple Injuries I recorded a conclusion that Callum died from suicide. 4 CIRCUMSTANCES OF THE DEATH Callum was sexually assaulted as a child. In his adult years, he developed substance misuse/addiction issues and it is likely he presented with complex PTSD or EUPD. He lived in social housing at Silverdale Court in Newquay. From approximately 2020, there started to be concerns that Callum was being cuckooed. In 2023, following the receipt of safeguarding alerts, it became apparent substantial damage had been caused at the flat which was uninhabitable. Callum was sleeping rough elsewhere. Temporary accommodation was arranged in Roche and Wadebridge but Callum was not allowed to remain at the addresses after drug paraphernalia was discovered. Callum continued to sleep rough apart from a short period when he was housed by the local authority under a severe weather protocol. In early 2024, a Notice Seeking Possession of the flat at Silverdale Court was served on Callum. On 19/1/24, Callum was seen in a distressed state having been involved in an altercation and complaining that his medication had been stolen. He went to a cliff edge in Newquay. Police attended and eventually removed 1 Information Classification: CONTROLLED Callum from the cliff. He was taken to a place of safety by police and underwent a mental health act assessment. He was determined not to be presenting with a severe and enduring mental illness of a nature and degree to warrant detention in hospital. Further, by the end of the period of assessment Callum’s risk to himself was not felt to be sufficiently imminent or significant to justify short-term detention. Callum was discharged and provided with a taxi to take him back to his emergency accommodation. There was a discussion about whether Callum wanted members of his family informed of his discharge. Callum said that he did not and this decision was not tested or challenged. It was not felt appropriate to breach the duties of confidentiality owed to Callum in this regard. Callum’s body was recovered from the sea at a location known locally as in Newquay on 20/1/24. He had suffered multiple injuries consistent with a fall from height. Additionally, post-mortem toxicology revealed evidence of cocaine metabolites, diazepam, mirtazapene, pregabalin, zopiclone and methadone. The methadone in particular was at a high level and sufficient to have caused death on its own. The pregabalin and zopiclone were also present at high levels. On the evidence, it is more likely than not that Callum has jumped or fallen from the cliffs with the intention of ending his own life. 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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 court heard that, as at January 2025, there were approximately 26,000 families registered on the Cornwall Homechoice Register which is the service for letting council and housing association homes to rent in Cornwall. The court also heard there may only be about 1,000 properties available to let annually. This has obvious implications for Cornwall Council’s ability to provide accommodation for those who are homeless whether or not they present with priority needs. As matters of fact, it was established in evidence that there were long periods when Callum was homeless and further, that frustrations in relation to his housing situation contributed to his mental state at the time of his death. 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. 2 Information Classification: CONTROLLED 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 July 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: , mother - - - Cornwall Council - Sanctuary Housing - Cornwall Partnership Foundation Trust , father and step-mother 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 [DATE] [SIGNED BY CORONER] 28.5.25 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.
Mr Andrew J. Cox
H. M. Senior Coroner
Cornwall and the Isles of Scilly Coroner’s Area
Deputy Prime Minister and Secretary of State for
Housing, Communities & Local Government
2 Marsham Street
London
SW1P 4DF
Our reference:
17 July 2025
Dear Mr Andrew J. Cox,
RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO
THE DEATH OF CALLUM JAMES HARGREAVES
Thank you for your letter and investigative report dated 28 May 2025 into the tragic death of Callum
James Hargreaves, 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 to you for bringing this case to my attention, and for your conduct of the inquest.
First, I want to express my sincere condolences to Mr Hargreaves’ family and friends. I was
distressed to read about his death, and the circumstances that led to him taking his own life.
Providing safe, secure and affordable housing for those in need is of vital importance to this
government. We are committed to delivering a substantial increase in good quality social housing.
In your report, you raise concerns about the failure to provide stable housing and adequate mental
health support for Mr Hargreaves, despite clear indicators of vulnerability, addiction, and risk of self-
harm. This response will focus on the steps I have taken, and will take, to support people out of
homelessness and increase the supply of social housing to meet demand, helping vulnerable people
to access it whilst tackling rogue practices such as cuckooing.
Matter of concern: The shortage of social housing and consequential homelessness
Social housing supply
It is distressing to learn that Mr Hargreaves’ mental health deterioration was exacerbated by his
housing situation. As indicated in the matter of concern, the number of households registered on
the Cornwall local authority waiting list (25,625 as of 31 March 2024) far exceeds the number of
available properties. This is something regrettably replicated across the country and can only be
described as a housing crisis, with over 1.3 million households on waiting lists in total.
Although the number of households on the waiting list is not the same as the number of households
waiting for social housing (due to factors such as households appearing on multiple local authority
housing registers), this data highlights that there is a high demand for social housing in Cornwall,
and across England. Unfortunately, even those with priority for social housing may have to wait for
some time before a home that meets their needs becomes available.
The government has committed to addressing this problem by delivering the biggest increase in
social and affordable housebuilding in a generation. We are working urgently to increase supply so
that those in society who are most vulnerable, such as Mr Hargreaves, are provided with safe and
secure social housing to help them build their lives.
That is why at the Spending Review on 11 June, the Chancellor confirmed a new £39 billion Social
and Affordable Homes Programme, running from 2026 to 2036. For the first time in living memory,
we are giving providers a decade-long funding settlement, providing the certainty they need to scale
up the building of the social homes we urgently require to meet demand.
Alongside this, we are providing a ten-year rent settlement so that social housing providers have
the certainty to invest in their current homes and build new ones.
The government also made a manifesto commitment to protect existing social rented stock, and we
have already taken action to achieve this - in November 2024, maximum Right to Buy cash discounts
were returned to pre-2012 levels which we estimate will reduce sales from around 7,000 to 1,600 a
year. On 2 July, we announced further details about other aspects of our reform programme,
including regulations on quality and safety and Right to Buy, so that there is the clarity and certainty
needed to quickly ramp up investment in existing and new social housing stock.
We are also determined to ensure social housing stock is being used effectively to support those
most in need. Local authorities must have an allocation scheme to manage housing supply fairly,
often using waiting lists to fulfil this. By law, certain people, such as those that are homeless or those
needing to move for medical or welfare reasons, are given priority. Local authorities can also give
higher priority to those in urgent need, such as those who are homeless or with medial needs, which
mean they require urgent re-housing. Allocation schemes must also include policies on offering
choice or preferences for accommodation and applicants can request information and reviews of
decisions made about their housing applications.
Homelessness and rough sleeping
The government recognises that homelessness levels are far too high. This can have a devastating
impact on those affected, as tragically seen in Mr Hargreaves’ case. Your report specifically raises
concerns about Cornwall Council’s ability to accommodate people who are homeless. The
government has increased funding for homelessness and rough sleeping services by £233 million
to a total of £1 billion in 2025/26, including over £10.7 million for Cornwall Council. At the recent
Spending Review, we protected this record level of investment.
This £1 billion investment includes £633 million funding through the Homelessness Prevention Grant
for local authorities to provide homelessness support. It can be used flexibly according to local need,
including to provide accommodation for people who are homeless and to prevent homelessness. In
2025/26, Cornwall Council was allocated £4.2 million in funding for these purposes.
As part of our spending on homelessness and rough sleeping, the government is also providing
funding so that local authorities can support people who are rough sleeping in their area. The
2025/26 Rough Sleeping Prevention and Recovery Grant provides £185.6 million funding, including
over £3.5 million for Cornwall Council so that local authorities can support individuals sleeping rough,
at risk of sleeping rough, or at risk of returning to rough sleeping. Services provided through the
grant can include accommodation, outreach staff and specialist support services.
We are also providing £950m capital for the fourth round of the Local Authority Housing Fund - the
largest round of the fund to date - to support local authorities in England to increase the supply of
better-quality temporary accommodation. This investment aims to drive down the use of Bed and
Breakfasts for families with children, improve outcomes for families in temporary accommodation,
and to provide more stable, secure housing options for the most vulnerable, including those
experiencing homelessness, while they wait for a permanent home.
We know that many people experiencing rough sleeping have substance misuse needs and can
struggle to access the necessary support. In 2025/26, we are providing £58.7 million to local
authorities, including £1,516,587 to Cornwall Council, through the Rough Sleeping Drug and Alcohol
Treatment Grant (RSDATG). RSDATG funding delivers substance misuse services for people at
risk of or already sleeping rough in 83 local authorities and 4 pan-London projects. The grant funds
evidence-based drug and alcohol treatment and wraparound support to improve access to
treatment, including for those with co-occurring mental health needs, as shown in the case of Mr
Hargreaves. The funding is also used to reduce the numbers sleeping rough or experiencing
homelessness as a result of substance misuse and reduce deaths from drug and alcohol poisoning.
Response to wider factors in the case
Tenancy sustainment
I will now turn to the Notice Seeking Possession which was issued to Mr Hargreaves in early 2024
in regard to his social housing at Silverdale Court.
Social landlords may take action when there has been a breach of the terms of their tenancy. Whilst
the report is not clear on whether Mr Hargreaves was no longer living in the property at the time of
the eviction, this may have been the case. However, social landlords will generally try to work with
the tenant to resolve difficulties and seek to sustain the tenancy, only pursuing eviction as a last
resort. In doing so, they must ensure they follow procedures set out in the Regulator for Social
Housing’s Tenancy Standard around supporting tenants.
Where a satisfactory resolution cannot be reached, landlords may seek a possession order from the
courts on the basis that there has been a breach of a term in the tenancy agreement or one of the
other statutory grounds for possession has been made out. As soon as a landlord gives a tenant
notice that they are seeking to possess their home, free legal advice and representation is available
from the Housing Loss Prevention Advice Service.
It is regrettable that following Mr Hargreaves’ distressing experience and complex housing situation
that he was not supported in accessing accommodation more appropriate to his needs.
Cuckooing
The report highlights concern that Mr Hargreaves was a victim of cuckooing. The government
recognises the appalling harm that cuckooing can cause to victims. When a person’s home is taken
over against their will and used for criminal purposes, it is a serious violation that robs them of their
safety and security with devasting long-term impacts. As Mr Hargreaves’ case highlights, in some
cases cuckooing can force the victim to leave their home and become homeless.
The government is taking action to tackle cuckooing by introducing a new offence in the Crime and
Policing Bill. This offence will criminalise the act of taking over another person’s dwelling without
their consent in connection with criminal activity. The offence will be supported by statutory guidance
for police and non-statutory guidance for other agencies, including local authorities, housing, health
and social care. This will include guidance on how agencies should work together to identify
individuals at risk of cuckooing, with the aim of improving multi-agency safeguarding and support
for victims. Introduction of the new offence and guidance will increase awareness, strengthening
enforcement against perpetrators and helping to improve support and protection for victims.
My department is also working to publish good practice case studies to support landlords to deal
more effectively with antisocial behaviour where victims or perpetrators have mental health issues
and/or drug or alcohol addiction.
Mental health support
Mr Hargreaves’ mental health is a consistent theme in the report. The government recognises that
too many people with mental health issues, like Mr Hargreaves, are not getting the support or care
they need. Our mission is to improve mental health care across the whole spectrum of need from
poor mental wellbeing to common mental health disorders to severe mental illness. Therefore, we
are focusing on ensuring the NHS is providing the right support to the right people at the right time.
I hope that this information is helpful, and I wish again to express my deep condolences to Mr
Hargreaves’ family and friends.
Yours sincerely,
Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government
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