Prevention of Future Deaths reports · 2025

Callum Hargreaves

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 report28 May 2025
Reference2025-0259
DeceasedCallum Hargreaves
CoronerAndrew Cox
Coroner areaCornwall and Isles of Scilly
CategoryAlcohol, drug and medication related deaths · Suicide (from 2015) · Mental Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

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 Mhclg (PDF)
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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