June 6, 2025

Callum Hargreaves (3): Prevention of Future Deaths Report

Alcohol, drug and medication related deaths Mental Health related deaths Suicide (from 2015)

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Date of report: 28/05/2025

Ref: 2025-0261

Deceased name: Callum Hargreaves

Coroners name: Andrew Cox

Coroners Area: Cornwall and Isles of Scilly

Category: Alcohol, drug and medication related deaths | Suicide (from 2015) | Mental Health related deaths

This report is being sent to: Cornwall Council

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: 1. [REDACTED], Head of Housing Options, Cornwall Council
1	CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly.
2	CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3	INVESTIGATION and INQUEST On 22/5/25, I concluded the inquest into the death of Callum James Hargreaves who died on 20/1/24 aged 32. I recorded the cause of death as 1a) Multiple Injuries. I recorded a conclusion that Callum died from suicide.
4	CIRCUMSTANCES OF THE DEATH Callum was sexually assaulted as a child. In his adult years, he developed substance misuse/addiction issues and it is likely he presented with complex PTSD or EUPD. He lived in social housing at Silverdale Court in Newquay. From approximately 2020, there started to be concerns that Callum was being cuckooed. In 2023, following the receipt of safeguarding alerts, it became apparent substantial damage had been caused at the flat which was uninhabitable. Callum was sleeping rough elsewhere. Temporary accommodation was arranged in Roche and Wadebridge but Callum was not allowed to remain at the addresses after drug paraphernalia was discovered. Callum continued to sleep rough apart from a short period when he was housed by the local authority under a severe weather protocol. In early 2024, a Notice Seeking Possession of the flat at Silverdale Court was served on Callum. On 19/1/24, Callum was seen in a distressed state having been involved in an altercation and complaining that his medication had been stolen. He went to a cliff edge in Newquay. Police attended and eventually removed Callum from the cliff. He was taken to a place of safety by police and underwent a mental health act assessment. He was determined not to be presenting with a severe and enduring mental illness of a nature and degree to warrant detention in hospital. Further, by the end of the period of assessment Callum’s risk to himself was not felt to be sufficiently imminent or significant to justify short-term detention. Callum was discharged and provided with a taxi to take him back to his emergency accommodation. There was a discussion about whether Callum wanted members of his family informed of his discharge. Callum said that he did not and this decision was not tested or challenged. It was not felt appropriate to breach the duties of confidentiality owed to Callum in this regard. Callum’s body was recovered from the sea at a location known locally as [REDACTED] in Newquay on 20/1/24. He had suffered multiple injuries consistent with a fall from height. Additionally, post-mortem toxicology revealed evidence of cocaine metabolites, diazepam, mirtazapene, pregabalin, zopiclone and methadone. The methadone in particular was at a high level and sufficient to have caused death on its own. The pregabalin and zopiclone were also present at high levels. On the evidence, it is more likely than not that Callum has jumped or fallen from the cliffs with the intention of ending his own life.
5	CORONER’S CONCERNS During the course of these inquests, the evidence has revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. On the facts of this case, Callum had a social tenancy with Sanctuary Housing but it is recognised the Council will have professional relationships with a number of housing providers. Safeguarding alerts were raised that Callum was being cuckooed. There was then a ‘stand-off’ between Sanctuary and the Council as to who had responsibility for housing Callum. This was not resolved even though there were seven Safeguarding conferences held over half a year. It was felt by the Chair of the Safeguarding conferences that Callum had been failed and that the question of who was responsible for his accommodation should have been resolved much more quickly. Going forward, the Council may wish to reflect upon: – How it would like social housing providers with whom it has professional relationships to resolve concerns about the cuckooing of tenants. A separate Preventing Future Deaths report has been written to Sanctuary in this regard (with a copy sent to the Council); – How disagreements about who has responsibility for housing a cuckooed tenant who becomes effectively homeless may be resolved more rapidly; – Council witnesses held conflicting views as to whether a social tenancy disqualified a tenant from making a homelessness application. It is for the Council to decide how to ensure a consistent approach is taken by its staff. The situation generally is considered in greater detail at paragraphs 150- 160 of the attached judgement.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24.7.25. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
8	COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: – [REDACTED], mother – [REDACTED], father and step-mother – Sanctuary Housing – Cornwall Partnership Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9	[DATE] 28.5.25 [SIGNED BY CORONER]

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