Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0136, written 9 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Mar 2026 |
|---|---|
| Reference | 2026-0136 |
| Deceased | Taylor Maddox |
| Coroner | Stephen Covell |
| Coroner area | Devon, Plymouth and Torbay |
| Category | Suicide (from 2015) |
| Organisation named | Devon Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
His Majesty's Senior Coroner for The County of Devon, Plymouth and Torbay Philip Spinney 9 March 2026 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NORTH DEVON COUNCIL CORONER 1 I am Stephen Covell one of the Assistant Coroners for Coroner Area of Devon, Plymouth and Torbay 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. 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST 3 On 18 April 2024 Phillip Spinney Senior Coroner for the Coroner Area of Devon, Plymouth and Torbay commenced an investigation into the death of Taylor Malcolm Maddox formerly Darryn Malcolm Bell. I concluded the investigation at the end of the inquest on 26 February 2026. The conclusion of the inquest was that Taylor was pronounced deceased at 1436 on 9 April 2024 in his car at the car park at North Devon District Hospital Raleigh Park Barnstaple due to toxicity. The Deceased had taken his own life with an overdose of painkilling medication. The medical cause of death was 1a conclusion of suicide. Toxicity. I returned a short form The County of Devon, Plymouth and Torbay, County Hall, Topsham Road, Exeter, Devon, EX2 4QD Telephone: 01392 383636 Email: coroner@devon.gov.uk CIRCUMSTANCES OF THE DEATH Taylor was born on 22 April 1981 and was 42 years of age at the time of his death. Taylor had a history of mental health illness including depression and traits of personality disorders. Taylor had previously attempted to take his own life with drug overdoses on two occasions. On 9 February 2024 Taylor was admitted as an informal patient to Moorland View Psychiatric Ward North Devon District Hospital having presented the day before to the Emergency Department of the hospital saying that he had plans to take his own life and could not keep himself safe. Whilst at Moorland View Taylor explained that the principal triggers for his feelings of hopeless and the desire to end his life were joblessness and homelessness. Taylor was discharged from Moorland View on 21 March 2024. His mood and optimism about the future had improved. Part of the preparation for Taylor's discharge was for him to find accommodation to which he could move on discharge. Taylor had been designated a housing officer from North Devon Council to assist him find accommodation. Taylor reported that he was struggling to find accommodation due his being on benefits. He also reported that he was experiencing difficulties getting responses from the housing officer and as a consequence he had been unable to arrange a deposit to secure an offer of accommodation. Taylor's discharge facilitator at the hospital reported multiple attempts to contact the housing officer went unanswered. 4 An application to North Devon Council for emergency accommodation on discharge was rejected on the basis that Taylor did not meet the priority need criteria for temporary accommodation. Ultimately Taylor was unable to find to find permanent accommodation and was discharged to short term step-down accommodation available to him for a limited period. On 27 March 2024 the Home Treatment Team supporting Taylor received an email from North Devon Council Housing Department confirming that Taylor needed to source his own private rented accommodation. Taylor left the step-down accommodation on 3 April 2024. He indicated that his intention was to sleep in his car for a couple of days until his benefits arrived to enable him to finance temporary hotel accommodate while he found a job. The last contact with Taylor was on 3 April 2024. He failed to attend a follow up meeting with the Home Treatment Team on 5 April 2024 On 9 April 2024 Taylor was found unresponsive in his car which was parked in a corner of the car park of North Devon District Hospital. The County of Devon, Plymouth and Torbay, County Hall, Topsham Road, Exeter, Devon, EX2 4QD Telephone: 01392 383636 Email: coroner@devon.gov.uk CORONER’S CONCERNS During the course of the inquest the evidence 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. – Following Taylor's death Devon Partnership NHS Trust conducted a patient safety incident investigation. In the sections 'Safety Actions and Ongoing Improvement Work' and 'Summary of multi-disciplinary case discussion 27 January 2025' of the subsequent report, which followed the investigation, staff team members reported difficulties with securing housing for patients upon their discharge from hospital were exacerbated by challenges communicating with North Devon Council's Housing Options Service. Emails to the housing officer from the discharge facilitator on Taylor's behalf had not been answered and when a response was received, it was to advise that Taylor was not eligible for emergency accommodation and would need to source his own. The team also queried the rationale of the housing team which would decline a house to a person they deemed too high a risk but would often determine that a person leaving hospital was not high enough need to qualify for emergency accommodation and the highest level of priority.. 5 The staff team members at Devon Partnership NHS Trust considered that unstable housing likely contributed to Taylor's distress and difficulties in his last weeks , Taylor's Responsible Clinician at Moorview Ward, recorded difficulties which the team and Taylor had experienced due to lack of timely and effective responses from North Devon Council housing team in pages 31 and 32 his report dated 16 September 2024. .The particular concerns are; (1) Patients awaiting discharge from psychiatric hospital in North Devon are not being supported in a timely and effective way to assist them secure accommodation. (2) The assessment process for entitlement to emergency accommodation and/or other assistance with securing accommodation in North Devon does not give adequate weight to the vulnerability of those with a psychiatric illness and the potential effect of unstable housing and homelessness on their mental health. (3) If vulnerable persons being discharged from hospital are not being provided with adequate and timely housing support and their needs adequately assessed there is an increased risk that they will relapse and their mental state will deteriorate. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you North Devon Council have the power to take such action. YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 May 2026. I, the coroner, may extend the period. The County of Devon, Plymouth and Torbay, County Hall, Topsham Road, Exeter, Devon, EX2 4QD Telephone: 01392 383636 Email: coroner@devon.gov.uk 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Taylor's mother and Devon Partnership NHS Trust. 8 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 March 2026 Signature 9 Stephen Covell Assistant Coroner for the Coroner Area of Devon, Plymouth and Torbay. The County of Devon, Plymouth and Torbay, County Hall, Topsham Road, Exeter, Devon, EX2 4QD Telephone: 01392 383636 Email: coroner@devon.gov.uk
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.
Report to Mr Stephen Covell Assistance Cororner North Devon Council’s response to your Regulation 28 Report to prevent future deaths. Taylor Malcolm MADDOX formerly Darryn Malcolm BELL Deceased D.O.B: 22 April 1981 Inquest: 18 April 2024 Devon County Hall, Topsham Road, Exeter North Devon Council’s (NDC) response to the concerns raised. Concern No.1 Patients awaiting discharge from psychiatric hospital in North Devon are not being supported in a timely and effective way to assist them secure accommodation. Our legal duties (in brief) Under Part 7 of the Housing Act 1996 (as amended by the Homelessness Reduction Act 2017), the Council must: Carry out an assessment and agree a Personalised Housing Plan with applicants who are eligible and homeless or threatened with homelessness (s.189A, HRA 2017). Take reasonable steps to relieve homelessness for at least 56 days (Relief Duty: s.189B). Provide interim accommodation only where there is reason to believe an applicant may be (i) homeless, (ii) eligible, and (iii) in priority need (s.188). Have regard to the Homelessness Code of Guidance (notably Chapters 11 and 15) when exercising these functions. What happened in this case (timelines abridged) 08 Feb: Homeless application taken; officer attempted same-day contact. 14 Feb: Council engaged with the psychiatric ward (Devon Partnership NHS Trust) and agreed to speak the following week about discharge planning/housing. 04–06 Mar: Active three-way working continued; NHS indicated the client did not meet supported-housing thresholds and that B&B/hotel would likely worsen mental health. Council therefore targeted shared accommodation, identifying units and setting out steps (viewing, acceptance, benefits/rent calculations). 19–20 Mar: Council/NHS liaison continued; NHS sought urgent bed-release. Council considered priority-need and communicated its interim accommodation decision, while accepting the Relief Duty, issuing the Personalised Housing Plan, and sending lists of agents and an income/expenditure form. 20–21 Mar: NHS placed the client in a 10-day step-down bed to bridge to move-on; client identified a room and asked the Council to pay deposit and first week’s rent; the officer requested landlord details and income evidence to lawfully process rent-deposit assistance. 22–26 Mar: Follow-ups sent; the required affordability evidence and landlord details were still outstanding at the point contact ceased. Our records show sustained, timely and effective engagement, including out-of hours work by the case officer, continuous liaison with NHS colleagues, and a care plan consistent with NHS clinical advice (avoid B&B; pursue shared accommodation). Where the client found a room, we promptly took the steps needed to release rent-deposit assistance; however, we cannot lawfully commit public funds without (a) suitability/affordability checks and (b) minimum information (address/landlord/payment route). We believe timely and effective support was provided during the discharge pathway. The Council fulfilled its assessment, Relief Duty, and reasonable steps requirements, and worked proactively with the NHS. Where payment of a deposit/Rent in Advance was requested, we acted promptly but were law-bound to complete affordability and verification checks before releasing public funds. Our records show that repeated follow-ups were undertaken by the case officer, out of hours, whilst on annual leave and delayed for one day when the officer was poorly. Mr Maddox had been assessed as having capacity to complete these tasks. We would like it also to be taken into consideration that our Housing Officers hold a large caseload, often in excess of 40 households, and we have to rely on applicants providing the information. We didn’t hear from the NHS who were seeking authority to share data or the applicant for 12 working days. We accept that we could have asked for the outstanding information again, but this would not have overridden the statutory framework to assist the NHS to improve bed flow. Concern No.2 The assessment process for entitlement to emergency accommodation and/or other assistance with securing accommodation in North Devon does not give adequate weight to the vulnerability of those with a psychiatric illness and the potential effect of unstable housing and homelessness on their mental health. Our legal duties (in brief) Priority need (s.189(1)(c)) includes persons who are vulnerable as a result of mental illness or other special reason. The Supreme Court in Hotak v Southwark [2015] UKSC 30 directs that vulnerability must be assessed against the comparator of an ordinary person if made homeless, taking the applicant’s particular circumstances in the round; available support may be considered where realistic and reliable. Interim accommodation (s.188) hinges on “reason to believe” of possible priority need; this is a low threshold, but tied to evidence available at the time. Regardless of priority need, the Council must carry out s.189A assessments, agree Personalised Housing Plans, and take reasonable steps under the Relief Duty. What happened in this case The Council accepted and worked the Relief Duty, created a Personalised Housing Plan, and pursued non-B&B options in line with mental-health advice. In deciding interim accommodation, the officer considered the clinical information then available (including functional ability reported by clinical staff) alongside other circumstances. On that information, the officer did not have reason to believe the statutory priority-need test was likely met at that time. Notwithstanding the interim-accommodation outcome, the Council continued intensive relief activity, including property options, benefit checks, affordability work, and progressing deposit/rent in advance subject to lawful verification. We recognise the heightened risks for people with serious mental illness and the need to weight those risks in decision-making. In this case, we did give weight to psychiatric factors: we adapted our housing pathway to clinical advice (avoiding B&B), progressed shared accommodation, and worked to fund a room once identified. On the legal tests, we consider the vulnerability and interim accommodation decisions were reasoned on the evidence then available and the governing case law; simultaneously, we met our relief duties in full. We therefore respectfully do not accept that our assessment process systemically under-weights psychiatric vulnerability. Concern No.3 If vulnerable persons being discharged from hospital are not being provided with adequate and timely housing support and their needs adequately assessed there is an increased risk that they will relapse and their mental state will deteriorate. Our position We agree with the public-health principle expressed. The Council’s practice and actions in this case were aimed precisely at mitigating relapse risk: we worked with clinicians, avoided placements known to aggravate mental ill-health, accepted the Relief Duty, and moved at pace to underwrite a room subject to minimal but necessary checks. We must also ensure that public funds are used lawfully and sustainably, which is why affordability and verification are required before deposits/rent in advance are released. Those checks are part of ensuring that any placement is suitable and sustainable, thereby reducing relapse risk rather than deferring it. On the evidence, housing support was both timely and clinically attuned, and needs were actively assessed through the statutory homelessness framework. The tragic outcome does not reflect an absence of timely housing support by NDC in this case. Lessons learned and proposed improvements While we consider the Council’s actions complied with law and guidance and reflected good practice by the case officer (including sustained out-of-hours or on leave work), we will take the opportunity to strengthen our joint arrangements with NHS partners. We therefore propose to: 1. Joint psychiatric discharge protocol (NDC–DPT–RDUH): a single, time-bounded pathway defining roles, hand-offs, escalation triggers (e.g., no-contact or missing evidence), and a named-worker model. Target: draft by 30 June 2026; sign-off by 31 July 2026. 2. Mental-health vulnerability decision aide-mémoire: a brief tool for officers, aligned to Hotak, to ensure holistic weighting of psychiatric factors within s.189(1)(c) assessments. Target: June 2026. 3. Rent-deposit fast-track for clinically urgent discharges: a checklist and same-day verification route (landlord details, address, affordability snapshot) to accelerate lawful payments where hospital discharge is imminent. Target: pilot from May–June 2026. Head of PMO, Environmental Health and Housing North Devon District Council March 2026
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