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recurance

Rebecca Hayward

13 Oct 2022 · Coroner Gordon Clow · Nottinghamshire and Nottingham

The coroner's concerns

  1. 1. inaccurate assessment and plans

    “Assessments of persons with severe and multiple disadvantage are undertaken by persons with little or no experience or specialist training in homelessness and substance misuse, resulting in inaccurate assessment and plans”
  2. 2. delayed or denied appropriate care

    “Care Act assessments are only extended to include consideration of the individual's changed care needs in their new environment if the early assessment work identifies eligible care needs in their current circumstances, with the social care provision subsequently being dependant on a re-referral and where such re-referrals are resisted”
  3. 3. death from substance misuse

    “discharge to a hostel would result in Ms [name redacted] death from substance misuse”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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