North Devon District Council
Local Authority / Fire Service
Action Taken
• The Council engaged with the psychiatric ward to discuss discharge planning and housing. • The Council identified shared accommodation units and outlined steps for viewing, acceptance, and benefits/rent calculations. • The Council issued a Personalised Housing Plan and communicated its interim accommodation decision. (AI summary)
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Report to Mr Stephen Covell Assistance Cororner North Devon Council’s response to your Regulation 28 Report to prevent future deaths. Taylor Malcolm MADDOX formerly Darryn Malcolm BELL Deceased D.O.B: 22 April 1981 Inquest: 18 April 2024 Devon County Hall, Topsham Road, Exeter North Devon Council’s (NDC) response to the concerns raised. Concern No.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. Our legal duties (in brief) Under Part 7 of the Housing Act 1996 (as amended by the Homelessness Reduction Act
2017), the Council must: Carry out an assessment and agree a Personalised Housing Plan with applicants who are eligible and homeless or threatened with homelessness (s.189A, HRA
2017). Take reasonable steps to relieve homelessness for at least 56 days (Relief Duty:
s.189B). Provide interim accommodation only where there is reason to believe an applicant may be (i) homeless, (ii) eligible, and (iii) in priority need (s.188). Have regard to the Homelessness Code of Guidance (notably Chapters 11 and 15) when exercising these functions. What happened in this case (timelines abridged) 08 Feb: Homeless application taken; officer attempted same-day contact. 14 Feb: Council engaged with the psychiatric ward (Devon Partnership NHS Trust) and agreed to speak the following week about discharge planning/housing. 04–06 Mar: Active three-way working continued; NHS indicated the client did not meet supported-housing thresholds and that B&B/hotel would likely worsen mental health. Council therefore targeted shared accommodation, identifying units and setting out steps (viewing, acceptance, benefits/rent calculations). 19–20 Mar: Council/NHS liaison continued; NHS sought urgent bed-release. Council considered priority-need and communicated its interim accommodation decision, while accepting the Relief Duty, issuing the Personalised Housing Plan, and sending lists of agents and an income/expenditure form. 20–21 Mar: NHS placed the client in a 10-day step-down bed to bridge to move-on; client identified a room and asked the Council to pay deposit and first week’s rent; the officer requested landlord details and income evidence to lawfully process rent-deposit assistance. 22–26 Mar: Follow-ups sent; the required affordability evidence and landlord details were still outstanding at the point contact ceased.
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). 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 delayed 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. We didn’t hear from the NHS who were seeking authority to share data or the applicant for 12 working days. We accept that we could have asked for the outstanding information again, but this would not have overridden the statutory framework to assist the NHS to improve bed flow. Concern No.2 The assessment process for entitlement to emergency accommodation and/or other assistance with securing accommodation in North Devon does not give adequate weight to the vulnerability of those with a psychiatric illness and the potential effect of unstable housing and homelessness on their mental health. Our legal duties (in brief) Priority need (s.189(1)(c)) includes persons who are vulnerable as a result of mental illness or other special reason. The Supreme Court in Hotak v Southwark [2015] UKSC 30 directs that vulnerability must be assessed against the comparator of an ordinary person if made homeless, taking the applicant’s particular circumstances in the round; available support may be considered where realistic and reliable. Interim accommodation (s.188) hinges on “reason to believe” of possible priority need; this is a low threshold, but tied to evidence available at the time. Regardless of priority need, the Council must carry out s.189A assessments, agree Personalised Housing Plans, and take reasonable steps under the Relief Duty. What happened in this case The Council accepted and worked the Relief Duty, created a Personalised Housing Plan, and pursued non-B&B options in line with mental-health advice. In deciding interim accommodation, the officer considered the clinical information then available (including functional ability reported by clinical staff) alongside other circumstances. On that information, the officer did not have reason to believe the statutory priority-need test was likely met at that time.
Notwithstanding the interim-accommodation outcome, the Council continued intensive relief activity, including property options, benefit checks, affordability work, and progressing deposit/rent in advance subject to lawful verification. We recognise the heightened risks for people with serious mental illness and the need to weight those risks in decision-making. In this case, we did give weight to psychiatric factors: we adapted our housing pathway to clinical advice (avoiding B&B), progressed shared accommodation, and worked to fund a room once identified. On the legal tests, we consider the vulnerability and interim accommodation decisions were reasoned on the evidence then available and the governing case law; simultaneously, we met our relief duties in full. We therefore respectfully do not accept that our assessment process systemically under-weights psychiatric vulnerability. Concern No.3 If vulnerable persons being discharged from hospital are not being provided with adequate and timely housing support and their needs adequately assessed there is an increased risk that they will relapse and their mental state will deteriorate. Our position 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. On the evidence, housing support was both timely and clinically attuned, and needs were actively assessed through the statutory homelessness framework. The tragic outcome does not reflect an absence of timely housing support by NDC in this case. Lessons learned and proposed improvements 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:
1. Joint psychiatric discharge protocol (NDC–DPT–RDUH): a single, time-bounded pathway defining roles, hand-offs, escalation triggers (e.g., no-contact or missing evidence), and a named-worker model. Target: draft by 30 June 2026; sign-off by 31 July 2026.
2. Mental-health vulnerability decision aide-mémoire: a brief tool for officers, aligned to Hotak, to ensure holistic weighting of psychiatric factors within s.189(1)(c) assessments. Target: June 2026.
3. Rent-deposit fast-track for clinically urgent discharges: a checklist and same-day verification route (landlord details, address, affordability snapshot) to accelerate lawful payments where hospital discharge is imminent. Target: pilot from May–June
2026.
Head of PMO, Environmental Health and Housing North Devon District Council March 2026
2017), the Council must: Carry out an assessment and agree a Personalised Housing Plan with applicants who are eligible and homeless or threatened with homelessness (s.189A, HRA
2017). Take reasonable steps to relieve homelessness for at least 56 days (Relief Duty:
s.189B). Provide interim accommodation only where there is reason to believe an applicant may be (i) homeless, (ii) eligible, and (iii) in priority need (s.188). Have regard to the Homelessness Code of Guidance (notably Chapters 11 and 15) when exercising these functions. What happened in this case (timelines abridged) 08 Feb: Homeless application taken; officer attempted same-day contact. 14 Feb: Council engaged with the psychiatric ward (Devon Partnership NHS Trust) and agreed to speak the following week about discharge planning/housing. 04–06 Mar: Active three-way working continued; NHS indicated the client did not meet supported-housing thresholds and that B&B/hotel would likely worsen mental health. Council therefore targeted shared accommodation, identifying units and setting out steps (viewing, acceptance, benefits/rent calculations). 19–20 Mar: Council/NHS liaison continued; NHS sought urgent bed-release. Council considered priority-need and communicated its interim accommodation decision, while accepting the Relief Duty, issuing the Personalised Housing Plan, and sending lists of agents and an income/expenditure form. 20–21 Mar: NHS placed the client in a 10-day step-down bed to bridge to move-on; client identified a room and asked the Council to pay deposit and first week’s rent; the officer requested landlord details and income evidence to lawfully process rent-deposit assistance. 22–26 Mar: Follow-ups sent; the required affordability evidence and landlord details were still outstanding at the point contact ceased.
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). 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 delayed 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. We didn’t hear from the NHS who were seeking authority to share data or the applicant for 12 working days. We accept that we could have asked for the outstanding information again, but this would not have overridden the statutory framework to assist the NHS to improve bed flow. Concern No.2 The assessment process for entitlement to emergency accommodation and/or other assistance with securing accommodation in North Devon does not give adequate weight to the vulnerability of those with a psychiatric illness and the potential effect of unstable housing and homelessness on their mental health. Our legal duties (in brief) Priority need (s.189(1)(c)) includes persons who are vulnerable as a result of mental illness or other special reason. The Supreme Court in Hotak v Southwark [2015] UKSC 30 directs that vulnerability must be assessed against the comparator of an ordinary person if made homeless, taking the applicant’s particular circumstances in the round; available support may be considered where realistic and reliable. Interim accommodation (s.188) hinges on “reason to believe” of possible priority need; this is a low threshold, but tied to evidence available at the time. Regardless of priority need, the Council must carry out s.189A assessments, agree Personalised Housing Plans, and take reasonable steps under the Relief Duty. What happened in this case The Council accepted and worked the Relief Duty, created a Personalised Housing Plan, and pursued non-B&B options in line with mental-health advice. In deciding interim accommodation, the officer considered the clinical information then available (including functional ability reported by clinical staff) alongside other circumstances. On that information, the officer did not have reason to believe the statutory priority-need test was likely met at that time.
Notwithstanding the interim-accommodation outcome, the Council continued intensive relief activity, including property options, benefit checks, affordability work, and progressing deposit/rent in advance subject to lawful verification. We recognise the heightened risks for people with serious mental illness and the need to weight those risks in decision-making. In this case, we did give weight to psychiatric factors: we adapted our housing pathway to clinical advice (avoiding B&B), progressed shared accommodation, and worked to fund a room once identified. On the legal tests, we consider the vulnerability and interim accommodation decisions were reasoned on the evidence then available and the governing case law; simultaneously, we met our relief duties in full. We therefore respectfully do not accept that our assessment process systemically under-weights psychiatric vulnerability. Concern No.3 If vulnerable persons being discharged from hospital are not being provided with adequate and timely housing support and their needs adequately assessed there is an increased risk that they will relapse and their mental state will deteriorate. Our position 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. On the evidence, housing support was both timely and clinically attuned, and needs were actively assessed through the statutory homelessness framework. The tragic outcome does not reflect an absence of timely housing support by NDC in this case. Lessons learned and proposed improvements 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:
1. Joint psychiatric discharge protocol (NDC–DPT–RDUH): a single, time-bounded pathway defining roles, hand-offs, escalation triggers (e.g., no-contact or missing evidence), and a named-worker model. Target: draft by 30 June 2026; sign-off by 31 July 2026.
2. Mental-health vulnerability decision aide-mémoire: a brief tool for officers, aligned to Hotak, to ensure holistic weighting of psychiatric factors within s.189(1)(c) assessments. Target: June 2026.
3. Rent-deposit fast-track for clinically urgent discharges: a checklist and same-day verification route (landlord details, address, affordability snapshot) to accelerate lawful payments where hospital discharge is imminent. Target: pilot from May–June
2026.
Head of PMO, Environmental Health and Housing North Devon District Council March 2026