Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0262, written 29 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 | 29 May 2025 |
|---|---|
| Reference | 2025-0262 |
| 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: , Chief Medical Officer, NHS Cornwall and IoS ICB. 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 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 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 1 Information Classification: CONTROLLED 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, I found it was more likely than not that Callum had jumped or fallen from the cliffs with the intention of ending his own life. 5 CORONER’S CONCERNS During the course of the inquest, 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. I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP. The MATTERS OF CONCERN relate to the arrangements made around Callum’s discharge and, in particular, safety planning. 1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely. 2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she 2 Information Classification: CONTROLLED had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further. It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent. It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP. 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 25.7.25. 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: - Callum’s family - Sanctuary Housing - Cornwall Council 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 3 Information Classification: CONTROLLED 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] 29.5.25 4
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.
Chief Medical Officer Carew House Beacon Technology Park Dunmere Road Bodmin Cornwall PL31 2 r.cftinquests@nhs.net 10th September 2025 FAO Mr Andrew Cox, HM Senior Coroner for Cornwall and the Isles of Scilly By Email: coronersservice@cornwall.gov.uk Dear Mr Cox Regulation 28 Report for the Prevention of Future Deaths made following the inquest into the death of Mr Callum Hargreaves I am writing in response to the Regulation 28 report, in my role as Chief Medical Officer for Cornwall Partnership NHS Foundation Trust. I would like to firstly offer my sincere condolences to Mr Hargreaves’ family. I am truly sorry for their loss. I am grateful for the opportunity that your report has provided to clarify the Trust’s position in relation to some of the queries raised within the expert evidence regarding discharge and safety planning. You set out in your report that there did not appear to be evidence that Mr Hargreaves’ decision not to inform his mother of his discharge was explored or tested by clinicians. Referring to GMC guidance, the expert felt that Mr Hargreaves’ Head office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN Call us on 01208 834 600 | Visit our website at cornwallft.nhs.uk reasons for declining consent could have been explored further with him. During the course of the inquest, the expert’s indication was not tested out with the Trust’s clinicians who had met with Mr Hargreaves, and this may have assisted with these concerns. The Trust values family engagement in the context of the care and treatment of their loved ones. There are a number on ongoing initiatives which will ensure that contact and appropriate liaison with families is a priority. The details of these are • Inpatient services have worked alongside carers to improve the information we provide at the point of admission, and we have processes in place to ensure that carers receive an information pack either in person, or through the post at the point that their loved one is admitted to the ward. • Our inpatient environments now have assistive technology enabling remote attendance at clinical review meetings to improve family engagement with the admission and discharge process. • Clinical review meetings are scheduled a week in advance giving family and carers the opportunity to link in with the ward team. • Our daily priority meetings highlight those patients that require carer support or input, allowing the nurse in charge the opportunity to allocate a staff member the responsibility to make contact with carers and families. • Family and carer involvement is embedded in the culture of the wards and is reported on and discussed at monthly performance meetings. • We are trialling a carers audit to improve carer engagement, ensuring weekly contact is documented, and consent to share information is fully documented and continually updated on RiO. This audit also checks whether carers views are documented regarding care and treatment, discharge planning, and ensuring that any incidents of note are shared depending on consent. • Each ward has an identified carers lead, and a working group has been established to consider how best to improve carer experience. • The Trust has a ‘Carers Corner’ which is a forum specifically set up to support carers. This is a Trust wide initiative, although carers of patients on mental Page 2 health wards can attend the forum and we are publishing the dates when they meet. • Carers are also invited to the 72-hour formulation meetings, allowing them the opportunity to talk about their concerns and worries and for the mental health team to get a good sense of risks and pre morbid presentation. It is important that contact with family is balanced against the wishes of the patient in cases where their level of risk is not such that there are grounds to override confidentiality, or them expressly declining consent to share information. Where a patient is detained under the Mental Health Act, and therefore there is a compulsory admission to hospital, there is an obligation upon the Approved Mental Health Practitioner to contact their next of kin to inform them of this fact. In cases where a patient does not meet the criteria for detention, and they are not admitted to a ward, a clinical judgement needs to be applied to determine whether their level of risk justifies going against any wishes regarding information sharing. In most patients who would not be deemed detainable under the Mental Health Act, it is unlikely that there would be such grounds to breach confidentiality. Mental Health Act assessments generally require some aspect of intrusive and sensitive questioning of a patient, at times over a long period. There may be periods of reflection and time for the assessing team to consider the status of a patient’s mental health away from the patient. Assessments may occur in a variety of complex and sometimes emotionally charged situations. The exploration of a patient’s decision making is finely balanced by those hoping to build trust and acceptance from patients. At the same time, this is implicit in the process of rapport building and general approach to the assessment. I am deeply sorry that Mr Hargreaves’ mother was not aware or made aware that Mr Hargreaves was being released from hospital. Exploring the reasons for a patient declining to share information with family is appropriate in many situations. This would take place on a case-by-case basis, considering factors such as the patient’s level of risk, their relationship with their family, the clinician’s therapeutic relationship with the patient, the context of the assessment and the need to build longer term trust with a patient. Making contact with families on the basis of such assessment continues to be a significant focus of the Trust and is a priority for clinicians. However, the appropriateness of testing a patient declining consent, or overriding Page 3 their wishes, will also continue to be assessed through the lens of clinical risk on a case-by-case basis. Yours sincerely, Chief Medical Officer Cornwall Partnership NHS Foundation Trust Page 4
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