Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0261, 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 | 2025-0261 |
| 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. , Head of Housing Options, Cornwall Council 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 22/5/25, I concluded the inquest into the death of Callum James Hargreaves who died on 20/1/24 aged 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 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 1 Information Classification: CONTROLLED 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) On the facts of this case, Callum had a social tenancy with Sanctuary Housing but it is recognised the Council will have professional relationships with a number of housing providers. Safeguarding alerts were raised that Callum was being cuckooed. There was then a ‘stand-off’ between Sanctuary and the Council as to who had responsibility for housing Callum. This was not resolved even though there were seven Safeguarding conferences held over half a year. It was felt by the Chair of the Safeguarding conferences that Callum had been failed and that the question of who was responsible for his accommodation should have been resolved much more quickly. Going forward, the Council may wish to reflect upon: - How it would like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants. A separate Preventing Future Deaths report has been written to Sanctuary in this regard (with a copy sent to the Council); - How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be 2 Information Classification: CONTROLLED resolved more rapidly; - Council witnesses held conflicting views as to whether a social tenancy disqualified a tenant from making a homelessness application. It is for the Council to decide how to ensure a consistent approach is taken by its staff. The situation generally is considered in greater detail at paragraphs 150- 160 of the attached judgement. 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 24.7.25. 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 - - - 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 Cox Senior Coroner for Cornwall and the Isles of Scilly Cornwall Coroners' Service Pydar House Pydar Street Truro TR1 1XU My ref: Date: 18th July 2025 Dear Mr Cox RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – MR WARNER, HEAD OF HOUSING OPTIONS CORNWALL COUNCIL We write in response to the Regulation 28 report (hereinafter referred to as the “Report” or “Reports”) provided to the Council ‘s Housing Options Service (hereinafter referred to as “Us”, “We”, “Our”) by the Senior Coroner on 28 May 2025 in relation to concerns raised following the inquest into the death of Callum Hargreaves. On behalf of Cornwall Council, and all those who personally attended the inquest, we would firstly wish to extend our sincere condolences to Callum’s family. Whilst it will in no way compensate for their loss, Callum’s family should rest assured that Cornwall Council remain determined to continually improve and develop the delivery of its services. We are grateful for the observations made by the learned Coroner in the Reports, which have assisted us in our policy of continuing development and improvement. For the purposes of clarity, and insofar as they relate to the local authority, we have extracted the points raised by the learned Coroner in the Reports. These are as follows: The Report “On the facts of this case, Callum had a social tenancy with Sanctuary Housing but it is recognised the Council will have professional relationships with a number of housing providers. Safeguarding alerts were raised that Callum was being cuckooed. There was then a ‘stand-off’ between Sanctuary and the Council as to who had responsibility for housing Callum. This was not resolved even though there were seven Safeguarding conferences held over half a year. It was felt by the Chair of the Safeguarding conferences that Callum had been failed and that the question of who was responsible for his accommodation should have been resolved much more quickly. Going forward, the Council may wish to reflect upon: How it would like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants…; How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be resolved more rapidly; Council witnesses held conflicting views as to whether a social tenancy disqualified a tenant from making a homelessness application. It is for the Council to decide how to ensure a consistent approach is taken by its staff.” The Concerns From the points raised above, and consideration of the Reports in totality, We understand that the learned Coroner seeks Our response to the following discrete concerns: Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk 1. How would the local authority like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants? 2. How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be resolved more rapidly. 3. How consistency in the determination of whether a social tenancy disqualified a tenant from making a homeless application may be achieved amongst staff. Action Taken and Our Response 1. While we cannot dictate what individual providers do operationally in terms of their own policy, we are in a position to promote and encourage the adoption of a unified understanding of cuckooing and, if possible, reach consensus in the following key areas; Where a social housing provider has concerns of suspected cuckooing, they engage as early as possible with partners (police, ASB, social care, Housing Options) by way of a multi-disciplinary meeting to reach agreement on cuckooing being a potential cause of harm or homelessness. Following this and with the engagement of the alleged victim, we would expect the following options to be considered (and documented) to resolve the concerns: a. Working closely with the police and the Council's ASB and Housing Options Teams, explore the potential for the obtainment of partial or complete closure of the demise and/or injunctions to exclude offenders from property. Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk b. The provision of an appropriate level of support to the resident in order to sustain the tenancy and live safely. c. Managed moves and relocation within their own housing stock when a resident is not able to continue to live safely in a property. d. Whether any contiguous legal duty to provide emergency accommodation, on an interim basis or otherwise, exists. In addition to the above, We have tabled this PFDO for the next Home Choice Partnership (Social Housing providers operating in Cornwall) meeting on the 16th of July 2025 to discuss these recommendations and track ongoing actions through this forum. 2. An escalation of Callum’s situation following the safeguarding/MDT meetings did not occur. Had the difficulties encountered triggered an escalation, then there may have been further opportunities to explore and potentially resolve the housing issue. In order to ensure this, managers and supervisors will be directed to the Council's ‘Escalation of Professional Differences Procedure and Guidance’ (- cios_sab-escalation-procedure-october- 2020.pdf). This document provides clear guidance on steps to resolve professional differences and strategic steps for the escalation of concerns. By August of 2025, all managers and supervisors will be able to demonstrate a thorough understanding of this document, its intended effect and its application. Furthermore, it is accepted that Callum’s individual case was not sufficiently highlighted through caseworker supervision. In light of this, we are currently reviewing the framework under which Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk caseworker supervisions take place to ensure that the highest levels of consistency and uniformity are maintained. We expect this review to be completed by the 31st of October 2025. We believe that the above steps will address the concerns raised by the learned Coroner. 3. We accept that an opportunity to open a case based on existing homelessness triggers under Part 7 of the Housing Act 1996 existed and that this could have been explored further. Of relevance to this matter was the fact that Callum had a tenancy. The question (and test) then of whether ‘…it [is] reasonable to occupy..’ should have been considered and applied following any concerns of alleged disrepair and suspected cuckooing. If the threshold for priority need was also met, then an offer of interim accommodation under s188 duty would be triggered. Accordingly, a Housing Options ‘all staff briefing’ has been held (June 2025) to reflect upon Callum’s specific case and highlight the importance of applying the correct homelessness test and whether the s.188 duty had been triggered. This will be supplemented by robust case worker supervision to ensure that the correct legal tests and thresholds are applied in each and every case. All staff to have access to, and be required to read and understand, the ‘Homelessness Code of Guidance’. This will be referred to in case worker supervision to ensure compliance and understanding. We will also implement a Quality Assurance Framework to ensure expertise and legal compliance. This will be achieved through a combination of rigorous induction training, continual professional development and continual case sampling. Once approved through internal governance, we expect this to be in place by 1st December 2025. Further considerations Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk In addition to the above, we considered the situation (as set out between paragraphs 150-160 of the judgement) generally so as to ascertain where improvements might be made. In order for employees to better understand the nature of cuckooing and thereby be better placed to identify and respond appropriately, Housing Options staff have completed e-learning training provided by Shelter on ‘cuckooing’. This will now form part of the training framework. This training will be completed on a bi-annual basis to ensure the knowledge is retained and current and will be mandatory for all new starters with Housing Options. It will be a requirement that this training be completed within the six-month probationary period for new starters. A subject matter expert (e.g. an ASB Officer) will be invited to speak at the next Housing Options staff away day. Closing Comments We trust the above has sufficiently addressed the concerns of the learned Coroner as articulated in the Report and sets out sufficiently the steps the local authority intends to take and the timetable for doing so. Finally, we would like to take the opportunity to thank you for highlighting these matters of concern and for the opportunity to respond. We would like to provide an assurance to Callum’s family that the findings of the learned Coroner will be positively acted upon and that the local authority will continue to work to improve practices to support the residents of Cornwall. Yours sincerely, Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk Head of Housing Options Cornwall Council New County Hall, Treyew Road, Truro TR1 3AY www.cornwall.gov.uk Cornwall Council | Konsel Kernow New County Hall, Treyew Road Truro TR1 3AY E: jon.warner@cornwall.gov.uk | T: 0300 1234 100 www.cornwall.gov.uk
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