Loraine Michelle CHEESMAN · Prevention of Future Deaths report

On 26/05/2023 14:31 an investigation was commenced into the death of Loraine Michelle CHEESMAN 12/06/1968 00:00:00. The investigation concluded at the end of the inquest on 03/04/2025 10:18. The conclusion of the inquest was that Died at ████████ Darlington, on 13 May 2023 as a consequence of a fire at the property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire..

Died at ████████, Darlington, on 13 May 2023 as a consequence of a fire at the property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire.

Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder:
“‘This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.”
During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour - a mental disorder or disorders.
So, the matter of concern consists of this request - for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached.