PFD report

Callum Hargreaves · Prevention of Future Deaths report

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Issued 28 May 2025•Cornwall and Isles of Scilly

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised4

  1. Failure to determine concerns of cuckooing of tenants
    Part of recurring concern: Inadequate protection of tenants from cuckooing
  2. Failure to determine responsibility for substantial damage to tenants’ homes
    Part of recurring concern: Inadequate protection of tenants from cuckooing
  3. Failure to work through an appropriate response to suspected cuckooing before seeking possession
    Part of recurring concern: Inadequate protection of tenants from cuckooing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Conduct an internal review following the Coroner’s findings to identify improvements to the multi-agency approach to ASB and cuckooing.

    Stated by Sanctuary Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 6 June 2025.
  2. Action

    Develop specific additional safeguarding and cuckooing guidance for front-line housing staff.

    Stated by Sanctuary Housing AssociationStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2025.
  3. Action

    Maintain a multi-agency approach to safeguarding adults, ASB and cuckooing in accordance with existing policies and procedures.

    Stated by Sanctuary Housing AssociationStated completedThe respondent said that this action was complete when they made their response on 6 June 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The available evidence and police assessment did not establish that the tenant was being cuckooed.

    Stated by Sanctuary Housing AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate protection of tenants from cuckooing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate protection of tenants from cuckooing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate protection of tenants from cuckooing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to secure timely suitable alternative accommodation for vulnerable people.

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

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
Page 5 · response
Published 6 June 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

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
Page 6 · response
Published 6 June 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

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
Page 5 · response
Published 6 June 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

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
Page 6 · response
Published 6 June 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

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
Page 3 · response
Published 6 June 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

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
Page 3 · response
Published 6 June 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

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
Page 5 · response
Published 6 June 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Consider whether a wider review of safeguarding policies and procedures is required.

    Stated by Sanctuary Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 6 June 2025.
  2. 2

    Benchmark safeguarding policies and procedures externally against those of other social housing organisations.

    Stated by Sanctuary Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 6 June 2025.

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

Consider whether a wider review of safeguarding policies and procedures is required.

Verbatim wording from the response

“(b) Sanctuary will externally benchmark its policies and procedures against others in the social housing sector and consider if a wider review of safeguarding policies and procedures are required.”

Source location

Response from Sanctuary Housing
Page 5 · response
Published 6 June 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

Benchmark safeguarding policies and procedures externally against those of other social housing organisations.

Verbatim wording from the response

“(b) Sanctuary will externally benchmark its policies and procedures against others in the social housing sector and consider if a wider review of safeguarding policies and procedures are required.”

Source location

Response from Sanctuary Housing
Page 5 · response
Published 6 June 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026