14 Apr 2026 Catherine Oliver · Prevention of Future Deaths report Oxfordshire
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Concerns raised 3 Failure to specify mitigating steps when household storage extends beyond a short-term period View source Hazardous storage of large quantities of boxed household items in living areas causing restricted movement or trip hazards View source Lack of clear time limits for storage of household items within living areas View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Catherine Oliver · 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
Catherine Oliver, aged 88, fell at home in a confined space between her armchair and boxes that had remained in her living room for nearly four weeks during housing works. She later died following complications arising from a fractured neck of femur sustained in the fall. The substantive concerns were the prolonged storage hazard, the absence of clear controls or time limits, and the potential risk to other elderly, disabled or mobility-restricted tenants.
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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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to specify mitigating steps when household storage extends beyond a short-term period
Wider context from the report “(a) Hazard created by prolonged storage of household items
The storage of large quantities of boxed items within the main living area for an extended period created a significant hazard, particularly for an elderly and potentially vulnerable tenant.
(b) Lack of clear controls or time limits
There appeared to be no clear policy or instruction governing :
• how long household items may be stored within living areas as part of necessary works; or
• what mitigating steps should be taken when such storage extends beyond a minimal or short-term period .
(c) Risk to other tenants
In my view, if similar circumstances were to arise in other properties—particularly those occupied by elderly, disabled or mobility-restricted tenants—there is a risk of future deaths or serious injury arising from restricted movement or trip hazards.
” 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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Hazardous storage of large quantities of boxed household items in living areas causing restricted movement or trip hazards
Wider context from the report “(a) Hazard created by prolonged storage of household items
The storage of large quantities of boxed items within the main living area for an extended period created a significant hazard , particularly for an elderly and potentially vulnerable tenant.
(b) Lack of clear controls or time limits
There appeared to be no clear policy or instruction governing:
• how long household items may be stored within living areas as part of necessary works; or
• what mitigating steps should be taken when such storage extends beyond a minimal or short-term period.
(c) Risk to other tenants
In my view, if similar circumstances were to arise in other properties—particularly those occupied by elderly, disabled or mobility-restricted tenants—there is a risk of future deaths or serious injury arising from restricted movement or trip hazards .
” 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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Lack of clear time limits for storage of household items within living areas
Wider context from the report “(a) Hazard created by prolonged storage of household items
The storage of large quantities of boxed items within the main living area for an extended period created a significant hazard, particularly for an elderly and potentially vulnerable tenant.
(b) Lack of clear controls or time limits
There appeared to be no clear policy or instruction governing :
• how long household items may be stored within living areas as part of necessary works ; or
• what mitigating steps should be taken when such storage extends beyond a minimal or short-term period.
(c) Risk to other tenants
In my view, if similar circumstances were to arise in other properties—particularly those occupied by elderly, disabled or mobility-restricted tenants—there is a risk of future deaths or serious injury arising from restricted movement or trip hazards.
” Open source report
Concerns raised 4 Failure to determine concerns of cuckooing of tenants View source Failure to determine responsibility for substantial damage to tenants’ homes View source Failure to work through an appropriate response to suspected cuckooing before seeking possession View source Delays in securing accommodation for tenants whose homes are uninhabitable View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to determine concerns of cuckooing of tenants
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.
” 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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to determine responsibility for substantial damage to tenants’ homes
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.
” 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 Sanctuary Housing Association; that does not assign responsibility.
PFD Monitor interpretation Failure to work through an appropriate response to suspected cuckooing before seeking possession
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.
” 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 Sanctuary Housing Association; that does not assign responsibility.
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.
” 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 Conduct an internal review following the Coroner’s findings to identify improvements to the multi-agency approach to ASB and cuckooing.
Verbatim wording from the response “(a) Sanctuary is committed to an internal review following the Coroner's findings to identify any improvements that can be made to our multi-agency approach to ASB and cuckooing.” Source location Response from Sanctuary Housing
Open published response
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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 specific additional safeguarding and cuckooing guidance for front-line housing staff.
Verbatim wording from the response “(d) In addition, Sanctuary's safeguarding leads are working to develop specific additional guidance for our front-line housing staff.” Source location Response from Sanctuary Housing
Open published response
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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 Maintain a multi-agency approach to safeguarding adults, ASB and cuckooing in accordance with existing policies and procedures.
Verbatim wording from the response “1.22 Sanctuary's Safeguarding Adults – Group Procedure is clear that Sanctuary operate a multi-agency approach to safeguarding adults. Sanctuary implements robust safeguarding procedures to protect its tenants and residents from harm and ensure their well-being. These procedures include reporting mechanisms, a commitment to partnership working with other agencies, and a focus on prevention and protection. These procedures are regularly reviewed and updated as required.” Source location Response from Sanctuary Housing
Open published response
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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 training and additional guidance complementing existing safeguarding and cuckooing policies and procedures, with external legal advisers.
Verbatim wording from the response “(c) In line with Sanctuary’s existing ASB Action Plan we are already considering training and additional guidance to complement existing policy and procedure around safeguarding and cuckooing, this will be developed in liaison with external legal advisors.” Source location Response from Sanctuary Housing
Open published response
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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 available evidence and police assessment did not establish that the tenant was being cuckooed.
Verbatim wording from the response ““I was never able to provide any creditable evidence to support the various claims that Callum was being Cuckooed. In fact, I concluded the view that he wanted these people in his life at the time”.” Source location Response from Sanctuary Housing
Open published response
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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 officers cannot assess mental capacity, and action may be limited where a tenant with capacity denies being cuckooed.
Verbatim wording from the response “1.11 Where cuckooing is reported as taking place at a tenant’s property, either the Police or Sanctuary would make a referral to Social Services and there would be a multi-agency approach to tackle the issue. However, in many cases, if a tenant is deemed to have mental capacity and denies they are being cuckooed, there is limited action that could be taken, except for the involvement of the Police regarding any criminal activity taking place at that Property. Housing Officers are not trained or qualified to assess mental capacity but if there were concerns identified these would be raised to social services or similar.” Source location Response from Sanctuary Housing
Open published response
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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 Existing safeguarding procedures and multi-agency arrangements will continue as the response to safeguarding and cuckooing concerns.
Verbatim wording from the response “1.22 Sanctuary's Safeguarding Adults – Group Procedure is clear that Sanctuary operate a multi-agency approach to safeguarding adults. Sanctuary implements robust safeguarding procedures to protect its tenants and residents from harm and ensure their well-being. These procedures include reporting mechanisms, a commitment to partnership working with other agencies, and a focus on prevention and protection. These procedures are regularly reviewed and updated as required.” Source location Response from Sanctuary Housing
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations