21 Aug 2023 Jacqueline Elizabeth Smith · Prevention of Future Deaths report West London
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Concerns raised 4 Lack of clear options and forward planning after failure of an assistance plan View source Insufficient staff training for dealing with complex hoarder cases View source Council hoarder-support guidance failing to support tenant assistance View source Failure to request required fire and environmental health assessments View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Deliver mandatory hoarding training to all Housing Management officers by the end of November 2023.
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Action
Develop and use an Operational Guidance Note covering hoarding case progression, recording, management oversight, tailored plans, handovers and ongoing review.
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Action
Use one revised hoarding flow chart that prompts safety referrals and supports consistent risk assessment and tenant-focused casework.
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AI-generated summary
Jacqueline Elizabeth Smith · 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
Jacqueline Elizabeth Smith took her own life by overdosing on prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. She had poor physical health and considerable anxiety while seeking council assistance with hoarded possessions, and a mental health assessment was not performed after she contacted a crisis telephone service. The inquest identified concerns including insufficient staff training for complex hoarder cases, missing safety assessments, an unsuitable council flow chart, and a lack of clear options after the initial assistance plan failed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Hillingdon; that does not assign responsibility.
PFD Monitor interpretation Lack of clear options and forward planning after failure of an assistance plan
Wider context from the report “(4) It was entirely unclear what options were available (if any) when the first plan of assistance completely failed , leaving the vulnerable tenant excluded from her property with no forward plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Hillingdon; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training for dealing with complex hoarder cases
Wider context from the report “(1) The inquest identified that there was insufficient staff training to deal with complex hoarder cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Hillingdon; that does not assign responsibility.
PFD Monitor interpretation Council hoarder-support guidance failing to support tenant assistance
Wider context from the report “(3) The council "flow chart" was clearly not fit for purpose to assist staff in progressing hoarder support and assistance and was focussed on enforcement procedures rather than tenant support . The inquest was advised that the council's approach was not enforcement, but their documentation did not support this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Hillingdon; that does not assign responsibility.
PFD Monitor interpretation Failure to request required fire and environmental health assessments
Wider context from the report “(2) Other safety assessments such as a fire assessment and/or environmental health assessment were not requested despite their being a clear need.
” Open source report
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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 mandatory hoarding training to all Housing Management officers by the end of November 2023.
Verbatim wording from the response “Although training has previously been delivered to Housing Management staff by Hoarding UK, further training will be delivered to all Officers within Housing Management by the end of November 2023 as part of mandatory annual refresher training across the Service.” Source location Response from London Borough of Hillingdon
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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 Develop and use an Operational Guidance Note covering hoarding case progression, recording, management oversight, tailored plans, handovers and ongoing review.
Verbatim wording from the response “The flow chart will form part of an Operational Guidance Note for staff which will provide further clarity on key stages of casework progression such as flagging hoarding cases in management by the Panel on the Housing Management data base (NEC Software Solutions) and referencing the case on the tenancy management file within Civica workflow to ensure any staff member working on the same tenancy is aware of the vulnerability and plan associated with live hoarding casework. This will also support management oversight of live casework.” Source location Response from London Borough of Hillingdon
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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 Use one revised hoarding flow chart that prompts safety referrals and supports consistent risk assessment and tenant-focused casework.
Verbatim wording from the response “The London Borough of Hillingdon has considered the concerns the Coroner has raised and has reviewed the flow charts and amalgamated them into one flow chart for all Officers. This action was completed at the end of September 2023. This single flow chart now ensures that all Officers are prompted to make referrals to the LFB and ASC as well as Environmental Health and the resident’s GP where appropriate, and this step becomes protocol for all cases of hoarding in management.” Source location Response from London Borough of Hillingdon
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations