Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0263, 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 | 2025-0263 |
| 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. , 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 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 1 Information Classification: CONTROLLED 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. At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024. 1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes. 2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not 2 Information Classification: CONTROLLED completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further. You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded. 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: , mother - - - Cornwall Partnership Foundation Trust - Sanctuary Housing , 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.
Information Classification: CONTROLLED
Mr Andrew Cox
Senior Coroner for Cornwall and the Isles of Scilly
Cornwall Coroners' Service
Pydar House
Pydar Street
Truro
TR1 1XU
Your ref:
My ref:
Date: 18 July 2025
Dear Mr Cox
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS, Mr HUSSEIN RUJAK,
HEAD OF SERVICE LEARNING DISABILITIES & MENTAL HEALTH, CORNWALL COUNCIL
We write in response to the Regulation 28 report (hereinafter referred to as the “Report” or
“Reports”) provided to the Council’s Adult Social Care Operations (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.
We can confirm that we have also had sight of the “Response to Regulation 28 Report to Prevent
Future Deaths provided to the Housing Options Service and would also wish to extend our deepest
condolences to the family of Callum. We hope Our responses will go some way in assuring the family
that, where improvements can be made, changes to existing practices and protocols will follow.
For 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
“1.
One issue that arose was whether Callum presented with an imminent and significant risk of
harm to justify a short-term admission into hospital as is provided for in NICE guidance.
said this was expressly discussed by the clinicians concerned. It was felt he was likely
Cornwall Council | Konsel Kernow
New County Hall, Treyew Road, Truro, TR1 3AY
E: hussein.rujak@cornwall.gov.uk | T: 0300 1234 100
www.cornwall.gov.uk
Information Classification: CONTROLLED
Information Classification: CONTROLLED
to be withdrawing and there were no resuscitation facilities available in Longreach. She also
said the vulnerabilities of others on the ward needed to be considered all of which contributed
to the decision not to detain Callum in hospital. She accepted that this rationale was not
recorded in the notes.
2.
Callum was asked whether he wanted his mother (who he described as his rock) notified of
his discharge. He said that he did not. This was not tested or challenged where GMC guidance
is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were
not completed.
The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as
Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to
involve her should have been explored further. You may feel these omissions should be learned from
when assessments are conducted in the future and, in particular, when notes of an assessment are
subsequently recorded.”
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:
1.
The potential insufficiency of notes evidencing the rationale behind the decision not to
detain Callum in hospital.
2.
Whether Callum’s instruction that he did not want his mother contacted about his admission
should have been further tested, challenged or explored.
3.
The adequacy of information recorded in notes.
Action Taken and Our Response
(For succinctness, Our response to 1 and 3 is set out at ‘1’ below)
Information Classification: CONTROLLED
Information Classification: CONTROLLED
1. It is acknowledged that in every instance where an assessment as to an individual’s suitability
for a short-term admission into hospital is being made, the rationale for admission or non-
admission should be clearly and accurately recorded. This is important to ensure consistency
in approach, adherence to all extant policies and guidance and to ensure that any rationale
underpinning any such decision can be fully understood.
From the 14th of May 2025, the local authority has been proactively implementing a change
in where Mental Health Act (MHA) assessments are recorded. This is a departure from the
current practice of recording on the health database (RIO) to recording on the Adult Social
Care database (Mosaic). This change will allow us to incorporate MHA assessments into our
audit programme, thereby supporting improved quality and consistency in documentation
and recording.
2. We accept that there was scope to explore and challenge Callum’s capacitous instruction
for us not to contact his mother more thoroughly and the views of the learned Coroner in
relation to the information that was recorded.
We have developed and disseminated guidance for Approved Mental Health Professionals
(AMHPs) on safety planning following assessments. This guidance has been shared with all
AMHPs within our service and is currently progressing through our governance processes
before formal adoption. Upon formal adoption, it will be implemented immediately
thereafter. Unfortunately, due to the systems of governance within the local authority, no
more precise details about timetabling can be provided at this point.
We believe that this guidance will provide greater clarity and assurance to practitioners on
the appropriateness of departing from accepted protocols on client confidentiality in
similar circumstances.
Closing Comments
We trust the above addresses the concerns of the learned Coroner and as contained in the Report.
We hope that the action taken and the steps the local authority intends to take provide the
assurance required.
Information Classification: CONTROLLED
Information Classification: CONTROLLED
We are grateful to the learned Coroner for his findings and for the opportunity to respond. We would
echo the sentiments of the Council’s Housing Options Service and would also like to assure Callum’s
family that the local authority will continue to work to improve practices to support the residents of
Cornwall.
Yours sincerely
Dhywgh hwi yn hwir
- Head of Learning Disabilities and Mental Health
Cornwall Council | Konsel Kernow | Care and Wellbeing | Gwith ha Sewena | Adult Social Care |
Tevesikwith Socyal
hussein.rujak@cornwall.gov.uk | Tel: 01872 322222 then say my full name
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