Recurring concern

Failure to secure timely suitable alternative accommodation for vulnerable people

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First reported 28 May 2021•Latest report 9 Mar 2026

Definition

What this concern includes

Includes failures in the dedicated process for identifying, arranging, supporting or completing moves to suitable alternative accommodation for vulnerable people, including inadequate support-service capacity, delayed placement or decant arrangements, and absent deadlines or tracking for finding an alternative.

Not included

  • Excludes general housing shortages or accommodation-capacity concerns where no specific vulnerable-person move or alternative-accommodation need is identified.
  • Excludes ordinary communication, bidding or administrative deficiencies unless they directly prevent or delay securing suitable alternative accommodation for a vulnerable person.
  • Excludes failures concerning ongoing support after suitable accommodation has been secured, unless they are part of the process of enabling the move.
  • Excludes hospital, psychiatric or social-care placement delays where the concern is not securing alternative accommodation for a vulnerable person.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2021–2026

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Housing, Communities and Local Government2
Cambridgeshire and Peterborough NHS Foundation Trust1
Cambridgeshire County Council1
Leeds and York Partnership NHS Foundation Trust1
National Police Chiefs’ Council1
North Devon District Council1
Sanctuary Housing Association1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Devon, Plymouth and Torbay

    AI-generated summary

    Taylor Malcolm Maddox · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Taylor Malcolm Maddox, who had a history of mental health illness and previous suicide attempts, was found unresponsive in his car on 9 April 2024 after leaving short-term accommodation and indicating he intended to sleep in the car. The inquest concluded that he had taken his own life by overdosing on painkilling medication. The principal concerns were delays and difficulties in securing suitable accommodation for psychiatric patients leaving hospital, and an assessment process that did not adequately account for psychiatric vulnerability and the effects of unstable housing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely and effective accommodation support for psychiatric hospital discharge patients in North Devon

    Wider context from the report

    “(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. ”

    Source location

    Taylor Malcolm Maddox · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and secure approval for a joint, time-bounded psychiatric discharge protocol defining roles, hand-offs, escalation triggers and named workers.

    Verbatim wording from the response

    “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:”

    Source location

    2026-0136 - Response from North Devon Council
    Page 3 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Pilot a rent-deposit fast-track using a checklist and same-day verification route for clinically urgent hospital discharges.

    Verbatim wording from the response

    “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:”

    Source location

    2026-0136 - Response from North Devon Council
    Page 3 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Timely and effective housing support was provided to the patient during the psychiatric discharge pathway.

    Verbatim wording from the response

    “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).”

    Source location

    2026-0136 - Response from North Devon Council
    Page 2 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deposit or rent-in-advance payments could not be released without required affordability, suitability and landlord verification information.

    Verbatim wording from the response

    “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).”

    Source location

    2026-0136 - Response from North Devon Council
    Page 2 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Housing assistance depended on applicants and partner agencies providing the information required to process support lawfully.

    Verbatim wording from the response

    “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 weekdays 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.”

    Source location

    2026-0136 - Response from North Devon Council
    Page 2 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The case did not demonstrate an absence of timely housing support or active needs assessment causing the adverse mental-health outcome.

    Verbatim wording from the response

    “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.”

    Source location

    2026-0136 - Response from North Devon Council
    Page 3 · response
    Published 12 March 2026

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Callum Hargreaves · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Callum Hargreaves died after his body was recovered from the sea in Newquay on 20 January 2024, having suffered multiple injuries consistent with a fall from height; the inquest recorded suicide. The principal concern was the response to suspected cuckooing of his social-housing flat, including uncertainty about who caused substantial damage, a period of homelessness, and the decision to serve a Notice Seeking Possession shortly before his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in securing accommodation for tenants whose homes are uninhabitable

    Wider context from the report

    “1) Callum had a flat at Silverdale Court in Newquay that was provided by Sanctuary Housing. From circa 2020, there were concerns that he was being cuckooed. A new Housing officer was appointed in mid-2022 and was made aware of these concerns although information from the police was that Callum had invited others into the flat. The Officer tried to speak to Callum who proved evasive. The Officer was surprised when a survey conducted in mid-2023 revealed over £10,000 damage, that the flat was uninhabitable and likely had been for some time. This gave rise to the question of who would accommodate Callum going forward. The issue was discussed at seven Safeguarding conferences. Sanctuary Housing agreed to provide Callum with decant accommodation out of goodwill but there was a lengthy period when Callum was homeless and sleeping rough. The issue of whether Callum was being cuckooed or not appeared not to have been determined while he was alive. At inquest, it was established he had been. The issue of who had caused the damage at Callum’s flat ie Callum himself, or those who had cuckooed him, appeared not to have been explored or determined during his life. At inquest, it was felt more likely to have been done by those without permission to be in the flat. This led to the question of what was an appropriate response to the discovery of the damage. It was recognised that a tenant who caused substantial damage to his flat may reasonably expect to be evicted by his landlord. Equally, it was felt that a vulnerable tenant ruthlessly exploited by thugs who took over his flat deserved support and assistance and not punishment. It was felt this had not been worked through by Sanctuary Housing before it made the decision to serve a Notice Seeking Possession on Callum who took his own life only weeks after its receipt. Going forward, the issue for Sanctuary Housing is how it should respond to concerns of cuckooing of its tenants. Please see paragraphs 150-160 of the enclosed judgment for further detail. ”

    Source location

    Callum Hargreaves · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Paul Williams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 9 July 2024, Paul Williams was found suspended from a ligature outside Screwfix, with police finding no suspicious circumstances. The inquest concluded that his death was suicide, with hanging recorded as the medical cause of death. The report identified eviction, homelessness, separation from his family while awaiting accommodation, and the resulting impact on his mental health as substantive concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in providing suitable accommodation for priority homeless families

    Wider context from the report

    “The inquest heard that Paul Williams was a hard working family man in employment. He and his family had been evicted from their privately rented accommodation and became homeless. They were given a period of 2 weeks to leave the property and find alternative accommodation. Whilst looking for accommodation the family was forced to live in separate locations. In his case that included living in a vehicle in the week. The inquest was told that the family was a priority case but a shortage of public housing meant that in total they had to wait almost 3 months before suitable accommodation became available. The evidence before the inquest was that the housing situation including the eviction, the homelessness and need to live separately whilst waiting for suitable accommodation to become available had a significant impact on his mental health and contributed to his deteriorating condition. ”

    Source location

    Paul Williams · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind Stockport Metropolitan Borough Council to act early under the Homelessness Code of Guidance to prevent households reaching crisis situations.

    Verbatim wording from the response

    “I am sorry that steps were not taken to offer and provide more suitable accommodation before the family faced this stage. I am writing to SMBC to remind them of this part of the code and the need to take sufficient action early enough to prevent households from being placed in a crisis situation by remaining until a possession order or bailiff warrant is issued.”

    Source location

    Response from Ministry of Housing, Communities & Local Government
    Page 2 · response
    Published 21 January 2025

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver 1.5 million new homes by the end of the Parliament, including increased social and affordable housing.

    Verbatim wording from the response

    “This government is committed to delivering 1.5 million new homes by the end of this Parliament, including the biggest increase in social housing and affordable housebuilding in a generation. In October 2024 and again in February 2025, we announced additional funding for the Affordable Homes Programme, which will build more social and affordable new homes, including Social Rent homes.”

    Source location

    Response from Ministry of Housing, Communities & Local Government
    Page 4 · response
    Published 21 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide £1.2 billion through the Local Authority Housing Fund for local authorities to acquire and create homes for families at risk of homelessness.

    Verbatim wording from the response

    “The supply of temporary accommodation is extremely challenging nationwide. MHCLG administers the Local Authority Housing Fund, which is providing £1.2bn to local authorities to acquire and create homes for families at risk of homelessness and will create over 7,000 affordable homes for vulnerable families.”

    Source location

    Response from Ministry of Housing, Communities & Local Government
    Page 4 · response
    Published 21 January 2025

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with 20 local authorities through Emergency Accommodation Reduction Pilots to test approaches and initiate more suitable accommodation for homeless families.

    Verbatim wording from the response

    “Additionally, MHCLG is also working with 20 local authorities through the new programme of Emergency Accommodation Reduction Pilots to test innovative approaches and kickstart new initiatives to provide more suitable accommodation for homeless families.”

    Source location

    Response from Ministry of Housing, Communities & Local Government
    Page 4 · response
    Published 21 January 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local authorities, rather than the department, are responsible for assessing homelessness applications and providing suitable accommodation and support.

    Verbatim wording from the response

    “My department is clear that local authorities must step in and assist households when they have received a section 21 notice and do so in a timely way. My department is responsible for the statutory framework that governs homelessness. The Housing Act 1996 Part 7 sets out the duties local housing authorities have towards homeless households, including the responsibilities for assessment, accommodation, and support. The Housing Act makes clear that a household is considered threatened with homelessness if they receive a section 21 notice which expires within 56 days and as a consequence is owed various duties under that Act.”

    Source location

    Response from Ministry of Housing, Communities & Local Government
    Page 2 · response
    Published 21 January 2025

    Open published response

  4. Manchester South

    AI-generated summary

    Colin Waterhouse · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Colin Waterhouse, who had pancreatic cancer and was receiving palliative treatment, was found suspended by a ligature on 11 September 2023; the inquest conclusion was suicide and the medical cause of death was hanging. The report raised concerns that unsuitable social housing and a difficult digital bidding system affected his health and mental wellbeing, while available support lacked the capacity to help him move and the shortage of housing made alternative accommodation unlikely.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient support-service capacity to assist palliative care patients to move to alternative accommodation

    Wider context from the report

    “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life. The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that. In addition even if he made a bid the chances of success was extremely slim given the huge demand for property. The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000. ”

    Source location

    Colin Waterhouse · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Severe shortage of available alternative social housing

    Wider context from the report

    “The inquest heard evidence that the social housing where Mr Waterhouse lived was such that it was impacted his overall health and wellbeing after his terminal cancer diagnosis. It was recognised that his housing was impacting his mental wellbeing but the support services available to him (as a palliative care patient) did not have the resources/capacity to assist him in moving to alternative accommodation for the last few months of his life. The evidence was that because he lived in social housing he had to bid for alternative accommodation. The bidding process was digital and he struggled to manage that. In addition even if he made a bid the chances of success was extremely slim given the huge demand for property. The inquest was told as an illustration that the Housing Association that he was a tenant of had 35,000 properties but a waiting list of 17,000. ”

    Source location

    Colin Waterhouse · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Set out future Government investment in social and affordable housing at the Spending Review.

    Verbatim wording from the response

    “On 30 July, I set out our first steps in this Government’s plan to build the homes this country needs and to deliver on our commitment to the biggest growth in social and affordable housebuilding in a generation. We will set out details of future Government investment in social and affordable housing at the Spending Review, so that social housing providers can plan for the future and help deliver the biggest increase in affordable housebuilding in a generation.”

    Source location

    Response from DLUHC
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Set expectations that housing needs assessments consider households requiring Social Rent homes and that councils specify Social Rent delivery expectations.

    Verbatim wording from the response

    “In the first instance, this Government’s aspiration is to ensure that, in the first full financial year of this Parliament (2025-26), the number of Social Rent homes is rising rather than falling. I have also set out a clear expectation that housing needs assessments must consider those requiring Social Rent homes, and that local authorities should specify their expectations on Social Rent delivery as part of broader affordable housing policies. This includes testing whether there is more that could be done to support developments that are predominately or exclusively affordable tenures, in particular Social Rent.”

    Source location

    Response from DLUHC
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Test whether more can be done to support developments focused predominantly or exclusively on affordable tenures, particularly Social Rent.

    Verbatim wording from the response

    “In the first instance, this Government’s aspiration is to ensure that, in the first full financial year of this Parliament (2025-26), the number of Social Rent homes is rising rather than falling. I have also set out a clear expectation that housing needs assessments must consider those requiring Social Rent homes, and that local authorities should specify their expectations on Social Rent delivery as part of broader affordable housing policies. This includes testing whether there is more that could be done to support developments that are predominately or exclusively affordable tenures, in particular Social Rent.”

    Source location

    Response from DLUHC
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase councils’ flexibility to use Right to Buy receipts for replacement affordable homes, including combining receipts with section 106 contributions.

    Verbatim wording from the response

    “More immediately, we have increased the flexibilities on how councils can use their Right to Buy receipts. The Government has removed the caps on the percentage of replacements delivered as acquisitions and the percentage cost of a replacement home that can be funded using Right to Buy receipts, and councils have been given the ability to combine Right to Buy receipts with section 106 contributions. These flexibilities will be in place for an initial 24 months, subject to review.”

    Source location

    Response from DLUHC
    Page 4 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide £450 million through the Local Authority Housing Fund to support councils in delivering affordable homes.

    Verbatim wording from the response

    “To further empower and enable councils to build their own stock of affordable homes, I also confirmed £450 million investment in councils across England under the third round of the Local Authority Housing Fund. This will create over 2,000 affordable homes for some of the most vulnerable families in society, including families currently living in cramped and unsuitable bed and breakfasts.”

    Source location

    Response from DLUHC
    Page 4 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Create over 2,000 affordable homes through the third round of the Local Authority Housing Fund.

    Verbatim wording from the response

    “To further empower and enable councils to build their own stock of affordable homes, I also confirmed £450 million investment in councils across England under the third round of the Local Authority Housing Fund. This will create over 2,000 affordable homes for some of the most vulnerable families in society, including families currently living in cramped and unsuitable bed and breakfasts.”

    Source location

    Response from DLUHC
    Page 4 · response
    Published 14 May 2024

    Open published response

  5. West Yorkshire Eastern

    AI-generated summary

    Neil Peter Bastock · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to establish alternative accommodation and transition arrangements before discharge consideration

    Wider context from the report

    “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”

    Source location

    Neil Peter Bastock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Rescinding detention was not premature discharge because the patient agreed to remain in hospital informally; discharge was not imminent.

    Verbatim wording from the response

    “e. Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 4 November 2021

    Open published response

  6. Cambridgeshire and Peterborough

    AI-generated summary

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of in-area supported accommodation for adolescent mental health patients

    Wider context from the report

    “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC. I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area, so that admission to a mental health unit becomes more likely. ”

    Source location

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue discussing with the CCG and Local Authority how to meet needs for 24/7 in-home care, including bespoke arrangements or a fully funded service.

    Verbatim wording from the response

    “The discussion about the need for 24/7 in home care will continue with the CCG and the Local Authority and whether any needs are best met though bespoke arrangements, or the demand is such as to require a fully funded service.”

    Source location

    2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 2 June 2021

    Open published response
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Data last updated 7 September 2026