Source · Prevention of Future Deaths

Colin Williams

Ref: 2016-0008 Date: 11 Jan 2016 Coroner: Elizabeth Carlyon Area: Cornwall Responses identified: 0 / 1 View PDF

A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.

Date 11 Jan 2016
56-day deadline 11 Mar 2016
Responses identified 0 of 1
Other related deaths

Coroner's concerns

AI summary
A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
View full coroner's concerns
During (he course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that fulure dealhs will occur unless aclion is taken. In the circumstances it is my statutory duty lo report to you. _ Mr Colin Williams was known Io numerous agencies and personnel. At inquest evidence was given from Ocean Housing, Adult care, Heallh and Wellbeing, Taylors of Grampound, (he Police, Royal Cornwall Hospital (together with minutes of Complex planning meelings arranged by Cornwall Council on 11.11.12, 13.03.12) (he extent of his complex needs and tendency to self-neglect, particularly when under the influence of alcohol, Despite known lo have complex needs his body was not found for some weeks_ Those at inquest gave evidence that due lo the large number of potential agencies involved in his care, his age (below 65), and (he fact he had variable mental capacity due his chronic alcoholism (no mental heallh diagnosis) it made it difficult for Mr Williams to know which agency provided what service and whether they were free Or The being not_ This led to agency "blindness" preventing him from accessing helplfunding particularly at a lime of crisis (especially when he lacked capacity due to alcoholism). An example was given by Ocean Housing who had been involved with Mr Williams since 2011. Initially he was provided support (hrough this tenancy which was funded by Cornwall Council supporting people budget. In 2011 the way funding was provided was changed and Mr Williams no longer qualified. An independent living service was set up in which clients had t0 contribute lowards_ From this lime forward Mr Williams did nol engage as he had difficully in underslanding the structure His funding was made more complicaled by hospital admissionslcare home placements which meant on occasions he was left without funds due to the necessary paperwork being completed which he was unable to complete or understand on his own_ Those at inquest considered (hat this was nol an uncommon scenario; particular when a client had both heallh and social issues and (his was made even more difficult if were drug andlor alcohol dependant

Report sections

Investigation and inquest
Colin Keith Williams
Circumstances of the death
Colin Williams was found dead at his home address, 18 Tregonissey Close, St Austell on glh April 2013. He was found lying on (he kitchen floor with (hree jackets on, over his top and trousers in a state of decomposilion. house was well heated but in a neglected state (plates with mouldy food around house, all surfaces covered with hoarded itemslmedication) with evidence of Mr Williams excessively abusing alcohol. He was last known to be alive on 17 March 2013, It was not possible to establish the cause of death or whether neglect played a part in the death on the evidence at inquest: Mr Williams was well known to numerous agencies e.g: Social Service, GP , police RCHT, social houses and was known to be a vulnerable adult and to self-neglect
Action should be taken
In my opinion action should be taken to prevent future dealhs and believe your organisalions have the power (o take such aclion. To review the structure and interagency approach in supporting clients with multiple social and heallh needs (in particular to those wilh drug andlor alcohol dependency) to provide a more "joined up" approach to (he client with consideration of workers_

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Report details

Reference
2016-0008
Date of report
11 January 2016
Coroner
Elizabeth Carlyon
Coroner area
Cornwall

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Mar 2016.

Sent to

Cornwall Council Local Adult Safeguarding Board

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