Loraine Cheesman: Prevention of Future Deaths Report
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Date of report: 03/04/2025
Ref: 2025-0178
Deceased name: Loraine Cheesman
Coroners name: Crispin Oliver
Coroners Area: County Durham and Darlington
Category: Product related deaths | Mental Health related deaths
This report is being sent to: REDACTED
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 [REDACTED] | |
| 1 | CORONER I am Crispin OLIVER, Senior Assistant Coroner for the coroner area of County Durham and Darlington |
| 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 26/05/2023 14:31an investigation was commenced into the death of Loraine Michelle CHEESMAN 12/06/1968 00:00:00. The investigation concluded at the end of the inquest on 03/04/2025 10:18. The conclusion of the inquest was that Died at [REDACTED], Darlington, on 13 May 2023 as a consequence of a fire at the property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire.. |
| 4 | CIRCUMSTANCES OF THE DEATH Died at [REDACTED], Darlington, on 13 May 2023 as a consequence of a fire at the property. The Hoarding Disorder and Executive Dysfunction from which she suffered made a more than minimal contribution to the fire. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Department of Health and Social Care (2023), Care and Support Statutory Guidance, Section 14.17 states in relation to Self Neglect and Hoarding Disorder: “This covers a wide range of behaviour neglecting to care of one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self- neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.” During the course of the evidence I heard from social workers and safeguarding professionals than in relation to assessing whether “the point” had been reached in relation to an adult suffering from Hoarding Disorder and Executive Dysfunction there was no specific guidance and that such guidance would in future be welcome. Currently they are constrained by existing guidance for assessing mental capacity, which does not directly recognise Executive Dysfunction, or for assessing whether the adult’s behaviour constitutes a potentially chargeable criminal or regulatory offence, for example in relation to public nuisance, health hazard, or anti social behaviour, rather than the root cause of the behaviour – a mental disorder or disorders. So, the matter of concern consists of this request – for guidance to be provided as to how to incorporate consideration of Executive Dysfunction into the assessment of mental capacity and how to assess when the point when external intervention can be triggered has been reached. |
| 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 May 29, 2025. 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 I have also sent it to Darlington Safeguarding Partnerships Darlington Adult Social Care & Housing Services Careline Homecare [REDACTED] who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 | Dated: 03/04/2025 Crispin OLIVER Senior Assistant Coroner for County Durham and Darlington |