Sanctuary Housing
Other
Action Planned
Sanctuary Housing commits to an internal review following the Coroner's findings to identify improvements that can be made to its multi-agency approach to ASB and cuckooing, and will externally benchmark its policies and procedures against others in the social housing sector. They are considering training and additional guidance to complement existing policy and procedure around safeguarding and cuckooing, and developing specific guidance for front-line housing staff. (AI summary)
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Dear Mr Andrew Cox We refer to your Prevention of Future Deaths Report made on 28 2025, under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the conclusion of your inquest into the death of Callum Hargreaves ("Callum"), who died on 20 January 2024 at the age of 32 ("the PFD"). You recorded the cause of death as 1(a) Multiple Injuries and came to a conclusion that Callum died by way of suicide. The PFD is addressed to Sanctuary Housing which is the trading name of Sanctuary Housing Association, a Registered Society as defined in section one of the Co-Operative and Community Benefit Societies Act 2014 (Registration Number 19059R) 'Sanctuary"). Sanctuary is not-for-profit Registered Social Landlord with the Regulator of Social Housing (Registration number LO247). In the first instance, on behalf of everyone at Sanctuary, we would Iike to extend our deepest heartfelt condolences to Callum's loved ones and family at what has been and continues to be an incredibly difficult time for them: Sanctuary's mission is to build affordable homes and sustainable communities where people choose to live We are committed to continually learning to ensure that our policies and processes are appropriate for the delivery of our mission: No reference was made to Sanctuary receiving the PFD in your summing up at the inquest hearing, we were therefore only on notice of the PFD on publication, on 6 June 2025. Sanctuary thank you for providing this opportunity to reflect and respond. Your specific concerns, relating to Sanctuary , are recorded in the PFD at Box 4. On Sanctuary's reading of the PFD, the primary concern presented in relation to Sanctuary's policy approach to cuckooing: In responding, we will provide detail of what informed Sanctuary's approach in this matter: Through consideration of Box 4 of the PFD and paragraphs 150 160 of your summing Up, Sanctuary will also provide detail of its housing management approach, including the role of its housing officers, in its performance of its obligations as Callum's landlord. Cont'd
INVESTORS IN PEOPLE Sanctuary Housing Association an exempt charity Registered office: Sanctuary House, Chamber Court; Castle Street, Worcester; WRI Jza Registered as provider of social housing with the Regulator of Social Housing No. L0247 Registered Society No. 1P059R Printed on recycled paper May
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025 22- Sanctuary'$ response to concerns raised in the PFD: Background to Property and Housing Manaqement
1.1 Silverdale Court is a block of 10 self-contained one-bedroom flats, situated over three floors. All tenants at Silverdale Court live independently as general needs, social housing tenants Sanctuary does not provide support or care services Within this general needs context; Sanctuary delivers the service of a social landlord in line with its policies, procedures and processes. These policies aim to strike the right balance between Sanctuary's role as a landlord and allowing its residents to have independent quiet enjoyment of their homes
1.2 Callum entered into a periodic Starter Assured Shorthold Tenancy Agreement with Sanctuary which commenced on 21 January 2013 ("the Tenancy"): He lived at Silverdale Court, ("the Property") . The Tenancy Agreement was signed on 18 January 2013.
1.3 Callum's housing application came via Cornwall Home Choice (CHC): There was nothing in his housing application which suggested general needs accommodation was not suitable on terms such as the Tenancy. Callum's application did not contain details or reference to or alcohol dependency, medical conditions other than mental health concerns which meant he was treated as a priority applicant, or additional support needs_
1.4 ("SH") was the relevant Housing Officer employed by Sanctuary connection to the Property from September 2022_ The previous housing officer and SH had a handover As part of that handover, SH was made aware of the background information in relation to Callum and his flat;
1.5 The role of a Housing Officer includes responsible for providing a quality housing service_ ensuring that tenancies are being conducted in a satisfactory way and making sure that our properties are safe and attractive places to live The role is varied and includes working with the lettings team to allocate void properties, handling a range of situations including anti-social behaviour ("ASB"), attending evictions, liaising with tenancy enforcement agencies, dealing with complaints and co-ordinating tenancy terminations and changes and property clearance_ All Housing Officers are appropriately trained, including on matters of juarding: Our housing officers are supported by 24-hour customer contact hub and lettings and income officers_
1.6 SH was responsible for around 400 properties across part of Cornwall: On occasions where there were vacancies in the housing team SH (and other members of the team) would cover a wider area whilst recruitment was undertaken: At the inquest SH made it clear that 80% of his properties and tenants did not require specific attention as rent was paid on time_ no housing management issues were ongoing and raised repairs were completed: SH had sufficient capacity to deal with those properties and tenants that required input Cont'd Printed on recycled paper Sanctuary Housing Assaciation an exempt charity drug being safegl
Sanctuary Mr Andrew Cox Cornwall Coroner's Service July 2025 3- Concerns About Cuckooing
1.7 It is understood that Police Constable and the Devon Cornwall Constabulary interacted_with or about Calllum on numerous occasions between February and July 2022 Imade clear to Callum that he and those he was associating with were affecting the local community residents.
1.8 made attempts to reassure Callum that he help him get anyone out of his flat who he did not want there has stated, in his witness statement to the Coroner; that: was never able to provide any creditable evidence to support the various claims that Callum was being Cuckooed. In fact; concluded the view that he wanted these people in his life at the time
1.9 SH and had a number of meetings in connection to Callum and the Property. SH only managed to meet with Callum on one occasion, although he had tried to engage with on several occasions on visiting the Property , often accompanied by the Police Callum was mostly absent from the Property when visited.
1.10 explicitly confirmed to SH that he did not think that Callum was cuckooed. SH and Sanctuary , relied on the evidence of a qualified police constable in establishing that Callum was not cuckooed' That is to say confirmation satisfied Sanctuary that Callum and his Property were not being controlled or exploited for the commission of specified criminal activity.
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 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 place at that Property. Housing Officers are not trained nor qualified to assess mental capacity but if there were concerns identified these would be raised to social services or similar. Property _Damage
1.12 On 20 June 2023, a property survey was conducted regarding Silverdale Court; and concluded that the flat was in an unhabitable condition. On 2 2023, SH updated the records to note that the Property was in a terrible condition and unsafe. The Property was made secure through boarding and metal shutters were requested on a emergency order and these were fitted on 4 July 2023_
1.13 The Police and Sanctuary had previously explored the potential of a Closure Order; arranging to obtain a statement from Callum on 21 June 2023, however SH was unable to get in contact with Callum on attendance to the Property. Cont'd Printed on recycled paper Sanctuary Housing Association_ an exempt charity and could him being being taking July
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 2025
1.14 Callum was never forthcoming about the damage to his flat to Sanctuary_ As the Coroner noted in his summing up, the evidence as to whether Callum was being cuckooed was not entirely clear at the time.
1.15 Works required to the Property when void amounted to a cost of E11,275.62 This included works required to repair and clean the Property to a lettable condition
1.16 The Tenancy included obligations for Callum as tenant to keep the property in reasonably clean conditions and in decorative order; to make good damage caused by himself or his visitors, save for reasonable wear and tear; to carry out minor repairs; and to report any disrepair or defect in the Property to Sanctuary (whether caused by the tenant or otherwise)
1.17 Sanctuary's repair obligation as landlord specifically included provision that Sanctuary was not responsible for repairs or replacements needed to the Property or fixtures, fittings or effects because of neglect or damage caused by the tenant or visitors Temporary Accommodation
1.18 Although not required to do so, between 8 September 2023 until 21 November 2023,temporary decant accommodation; booked on a weekly basis, was arranged for Callum by Sanctuary due to the flat at Silverdale Court being uninhabitable: Sanctuary paid for this in the total cost of E6,537.64.
1.19 The accommodation arranged for Callum was mostly at the Travelodge, Bodmin Roche, except for the half-term holiday week in October 2023 when the accommodation was not available. During this week, Callum stayed at the Premier Inn, Wadebridge, however due to his behaviour towards staff, Callum was banned from staying there: On 29 November 2023, staff at the Travelodge contacted Sanctuary to advise that drug paraphernalia had been found in Callum's room, therefore he had also been banned from staying there.
1.20 On 29 November 2023, a letter was sent to Callum (clo his mother's address) to explain that Sanctuary had been providing temporary accommodation whilst significant works were carried out at Silverdale Court: The letter advised that Sanctuary had been contacted by the Travelodge and Premier Inn to advise they would no longer provide accommodation to Callum due to acts contravening their booking terms and conditions The letter confirmed that as a result; Sanctuary Housing was no longer able to provide any further temporary accommodation:
1.21 On the advice of the Police that Callum was not being cuckooed, Sanctuary issued a Notice Seeking Position on January 2024 to begin the process of regaining possession of the Property from Callum. Cont'd Printed on recycled paper Sanctuary Housing Association, an exempt charity July good being
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025 5- SafequardingIMulti-Agency Approach
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.
1.23 In relation to Callum; a safeguarding alert was raised by "We Are With You" in April 2023. That resulted in a Section 42 Safeguarding inquiry, under the control of the Local Authority, which Sanctuary cooperated and participated in: A total of seven safeguarding meetings were held on 10 July 2023; August 2023; 30 August 2023; 8 September 2023; 9 October 2023_ 20 November 2023, 8 January 2024_
1.24 SH attended and fully engaged in five of those meetings, only being unable to attend on 07/08/2023 and 08/01/2024. The Safeguarding inquiry was always fully updated by SH, including Sanctuary's intention to take possession of Callum's flat; (meetings held on 09/10/2023 and 20/11/2023). In addition, SH's Area Manager also attended one of these safeguarding meetings.
1.25 Sanctuary acknowledges the Coroner's confirmation that a multi-agency approach existed in relation to this matter: Sanctuary can confirm that it will continue to exercise such an approach in line with its existing detailed policies and procedures. Sanctuary is reliant on the provision of relevant information from other agencies and acting in conjunction with them, will respond appropriately.
1.26 On 8 July 2025, Sanctuary's safeguarding lead had a conversation with the Chair of the local Safeguarding Board 'the Board") involved with Callum We asked whether a Safeguarding Adults Review ("SAR") was completed after Callum passed away. Following this prompt from Sanctuary , the Board are now liaising with Cornwall Council on this issue to establish whether a SAR has been undertaken to date: If a SAR is subsequently undertaken Sanctuary will take it as an opportunity to collectively review and learn for the future to ensure a proactive multi- agency approach.
1.27 In relation to the Coroner's advisory recommendations, in so far as these relate to Sanctuary, we can assure the Family and the Coroner that as an organisation we take our responsibilities extremely seriously and our focus and priorities are always directed towards the best interests our tenants: (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: (b) Sanctuary will externally benchmark its policies and procedures against others in the social housing sector and consider if wider review of safeguarding policies and procedures are required. Cont'd Printed on recycled paper Sanctuary Housing Association, an exempt charity
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025
-6- (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_ (d) In addition, Sanctuary's safeguarding leads are working to develop specific additional guidance for our front-line housing staff.
1.28 Sanctuary welcomes the Crime and Policing Bill which, if passed into legislation, will create a new bespoke criminal offence to help tackle cuckooing activity. It is understood that this will include guidance on cuckooing, including information on how police and partners can support and safeguard victims of cuckooing: Sanctuary will ensure said guidance is reviewed to inform its continued multi-agency approach to tackling cuckooing: If you require any further information, then please do not hesitate to contact us Yours faithfulv Group Chief Executive Printed on recycled paper Sanctuary Housing Association, an exempt charity
INVESTORS IN PEOPLE Sanctuary Housing Association an exempt charity Registered office: Sanctuary House, Chamber Court; Castle Street, Worcester; WRI Jza Registered as provider of social housing with the Regulator of Social Housing No. L0247 Registered Society No. 1P059R Printed on recycled paper May
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025 22- Sanctuary'$ response to concerns raised in the PFD: Background to Property and Housing Manaqement
1.1 Silverdale Court is a block of 10 self-contained one-bedroom flats, situated over three floors. All tenants at Silverdale Court live independently as general needs, social housing tenants Sanctuary does not provide support or care services Within this general needs context; Sanctuary delivers the service of a social landlord in line with its policies, procedures and processes. These policies aim to strike the right balance between Sanctuary's role as a landlord and allowing its residents to have independent quiet enjoyment of their homes
1.2 Callum entered into a periodic Starter Assured Shorthold Tenancy Agreement with Sanctuary which commenced on 21 January 2013 ("the Tenancy"): He lived at Silverdale Court, ("the Property") . The Tenancy Agreement was signed on 18 January 2013.
1.3 Callum's housing application came via Cornwall Home Choice (CHC): There was nothing in his housing application which suggested general needs accommodation was not suitable on terms such as the Tenancy. Callum's application did not contain details or reference to or alcohol dependency, medical conditions other than mental health concerns which meant he was treated as a priority applicant, or additional support needs_
1.4 ("SH") was the relevant Housing Officer employed by Sanctuary connection to the Property from September 2022_ The previous housing officer and SH had a handover As part of that handover, SH was made aware of the background information in relation to Callum and his flat;
1.5 The role of a Housing Officer includes responsible for providing a quality housing service_ ensuring that tenancies are being conducted in a satisfactory way and making sure that our properties are safe and attractive places to live The role is varied and includes working with the lettings team to allocate void properties, handling a range of situations including anti-social behaviour ("ASB"), attending evictions, liaising with tenancy enforcement agencies, dealing with complaints and co-ordinating tenancy terminations and changes and property clearance_ All Housing Officers are appropriately trained, including on matters of juarding: Our housing officers are supported by 24-hour customer contact hub and lettings and income officers_
1.6 SH was responsible for around 400 properties across part of Cornwall: On occasions where there were vacancies in the housing team SH (and other members of the team) would cover a wider area whilst recruitment was undertaken: At the inquest SH made it clear that 80% of his properties and tenants did not require specific attention as rent was paid on time_ no housing management issues were ongoing and raised repairs were completed: SH had sufficient capacity to deal with those properties and tenants that required input Cont'd Printed on recycled paper Sanctuary Housing Assaciation an exempt charity drug being safegl
Sanctuary Mr Andrew Cox Cornwall Coroner's Service July 2025 3- Concerns About Cuckooing
1.7 It is understood that Police Constable and the Devon Cornwall Constabulary interacted_with or about Calllum on numerous occasions between February and July 2022 Imade clear to Callum that he and those he was associating with were affecting the local community residents.
1.8 made attempts to reassure Callum that he help him get anyone out of his flat who he did not want there has stated, in his witness statement to the Coroner; that: was never able to provide any creditable evidence to support the various claims that Callum was being Cuckooed. In fact; concluded the view that he wanted these people in his life at the time
1.9 SH and had a number of meetings in connection to Callum and the Property. SH only managed to meet with Callum on one occasion, although he had tried to engage with on several occasions on visiting the Property , often accompanied by the Police Callum was mostly absent from the Property when visited.
1.10 explicitly confirmed to SH that he did not think that Callum was cuckooed. SH and Sanctuary , relied on the evidence of a qualified police constable in establishing that Callum was not cuckooed' That is to say confirmation satisfied Sanctuary that Callum and his Property were not being controlled or exploited for the commission of specified criminal activity.
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 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 place at that Property. Housing Officers are not trained nor qualified to assess mental capacity but if there were concerns identified these would be raised to social services or similar. Property _Damage
1.12 On 20 June 2023, a property survey was conducted regarding Silverdale Court; and concluded that the flat was in an unhabitable condition. On 2 2023, SH updated the records to note that the Property was in a terrible condition and unsafe. The Property was made secure through boarding and metal shutters were requested on a emergency order and these were fitted on 4 July 2023_
1.13 The Police and Sanctuary had previously explored the potential of a Closure Order; arranging to obtain a statement from Callum on 21 June 2023, however SH was unable to get in contact with Callum on attendance to the Property. Cont'd Printed on recycled paper Sanctuary Housing Association_ an exempt charity and could him being being taking July
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 2025
1.14 Callum was never forthcoming about the damage to his flat to Sanctuary_ As the Coroner noted in his summing up, the evidence as to whether Callum was being cuckooed was not entirely clear at the time.
1.15 Works required to the Property when void amounted to a cost of E11,275.62 This included works required to repair and clean the Property to a lettable condition
1.16 The Tenancy included obligations for Callum as tenant to keep the property in reasonably clean conditions and in decorative order; to make good damage caused by himself or his visitors, save for reasonable wear and tear; to carry out minor repairs; and to report any disrepair or defect in the Property to Sanctuary (whether caused by the tenant or otherwise)
1.17 Sanctuary's repair obligation as landlord specifically included provision that Sanctuary was not responsible for repairs or replacements needed to the Property or fixtures, fittings or effects because of neglect or damage caused by the tenant or visitors Temporary Accommodation
1.18 Although not required to do so, between 8 September 2023 until 21 November 2023,temporary decant accommodation; booked on a weekly basis, was arranged for Callum by Sanctuary due to the flat at Silverdale Court being uninhabitable: Sanctuary paid for this in the total cost of E6,537.64.
1.19 The accommodation arranged for Callum was mostly at the Travelodge, Bodmin Roche, except for the half-term holiday week in October 2023 when the accommodation was not available. During this week, Callum stayed at the Premier Inn, Wadebridge, however due to his behaviour towards staff, Callum was banned from staying there: On 29 November 2023, staff at the Travelodge contacted Sanctuary to advise that drug paraphernalia had been found in Callum's room, therefore he had also been banned from staying there.
1.20 On 29 November 2023, a letter was sent to Callum (clo his mother's address) to explain that Sanctuary had been providing temporary accommodation whilst significant works were carried out at Silverdale Court: The letter advised that Sanctuary had been contacted by the Travelodge and Premier Inn to advise they would no longer provide accommodation to Callum due to acts contravening their booking terms and conditions The letter confirmed that as a result; Sanctuary Housing was no longer able to provide any further temporary accommodation:
1.21 On the advice of the Police that Callum was not being cuckooed, Sanctuary issued a Notice Seeking Position on January 2024 to begin the process of regaining possession of the Property from Callum. Cont'd Printed on recycled paper Sanctuary Housing Association, an exempt charity July good being
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025 5- SafequardingIMulti-Agency Approach
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.
1.23 In relation to Callum; a safeguarding alert was raised by "We Are With You" in April 2023. That resulted in a Section 42 Safeguarding inquiry, under the control of the Local Authority, which Sanctuary cooperated and participated in: A total of seven safeguarding meetings were held on 10 July 2023; August 2023; 30 August 2023; 8 September 2023; 9 October 2023_ 20 November 2023, 8 January 2024_
1.24 SH attended and fully engaged in five of those meetings, only being unable to attend on 07/08/2023 and 08/01/2024. The Safeguarding inquiry was always fully updated by SH, including Sanctuary's intention to take possession of Callum's flat; (meetings held on 09/10/2023 and 20/11/2023). In addition, SH's Area Manager also attended one of these safeguarding meetings.
1.25 Sanctuary acknowledges the Coroner's confirmation that a multi-agency approach existed in relation to this matter: Sanctuary can confirm that it will continue to exercise such an approach in line with its existing detailed policies and procedures. Sanctuary is reliant on the provision of relevant information from other agencies and acting in conjunction with them, will respond appropriately.
1.26 On 8 July 2025, Sanctuary's safeguarding lead had a conversation with the Chair of the local Safeguarding Board 'the Board") involved with Callum We asked whether a Safeguarding Adults Review ("SAR") was completed after Callum passed away. Following this prompt from Sanctuary , the Board are now liaising with Cornwall Council on this issue to establish whether a SAR has been undertaken to date: If a SAR is subsequently undertaken Sanctuary will take it as an opportunity to collectively review and learn for the future to ensure a proactive multi- agency approach.
1.27 In relation to the Coroner's advisory recommendations, in so far as these relate to Sanctuary, we can assure the Family and the Coroner that as an organisation we take our responsibilities extremely seriously and our focus and priorities are always directed towards the best interests our tenants: (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: (b) Sanctuary will externally benchmark its policies and procedures against others in the social housing sector and consider if wider review of safeguarding policies and procedures are required. Cont'd Printed on recycled paper Sanctuary Housing Association, an exempt charity
Sanctuary Mr Andrew Cox Cornwall Coroner's Service 11 July 2025
-6- (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_ (d) In addition, Sanctuary's safeguarding leads are working to develop specific additional guidance for our front-line housing staff.
1.28 Sanctuary welcomes the Crime and Policing Bill which, if passed into legislation, will create a new bespoke criminal offence to help tackle cuckooing activity. It is understood that this will include guidance on cuckooing, including information on how police and partners can support and safeguard victims of cuckooing: Sanctuary will ensure said guidance is reviewed to inform its continued multi-agency approach to tackling cuckooing: If you require any further information, then please do not hesitate to contact us Yours faithfulv Group Chief Executive Printed on recycled paper Sanctuary Housing Association, an exempt charity