Coroner issues warning to government over gap in services for vulnerable people

A coroner has written to the government over concerns that a gap in services for vulnerable people with complex needs could lead to future deaths.

Adrian Farrow, assistant coroner for Greater Manchester South, sent a Prevention of Future Deaths report to the Department for Health and Social Care (DHSC) in the wake of an inquest into the death of a young recovering drug addict.

The inquest found that Jordan Clare, aged 22, took his own life in 2020 in the wake of a dispute with a neighbour. He had ADHD, attachment and conduct disorder and suffered from anxiety and depression, and had previously been addicted to Class A drugs, leading to spells in custody and restrictions on contact with his family.

During the later stages of the dispute with his neighbour in the summer of 2020, he began to voice intentions to take his own life, which he eventually did during a final call to a housing offender support worker.

The inquest found that while Clare had ‘significant support’ from multiple agencies – including the probation service, the police, a drug misuse charity and the local authority – there was no single individual or agency responsible for the co-ordination of the package of care, support and resources.

‘Whilst there was sharing of information between some individuals involved, it was not structured, formalised or supervised,’ the coroner’s report said. ‘In practice, the Housing Offender Support worker, whose role did not require any formal social work or mental health care qualifications became the person upon whom Mr Clare relied.’

The coroner’s report to the DHSC said that the inquest had heard evidence from a senior safeguarding staff member at Stockport council who highlighted a longstanding gap in provision, ‘which was described as extending across most if not all local authorities’, for vulnerable adults who have complex needs but do not fall into the existing framework of social services, Care Act provision or formal mental health supervision.

‘The effect of that gap is that there is no identifiable individual who is a single point of contact in such cases equivalent to a social worker or care coordinator,’ the coroner’s report said. ‘The result is that many vulnerable adults with complex needs have no such arrangements in place for contact, collating and sharing of information and deployment of services and assistance, support or safeguarding.

‘Where such arrangements are in place, they are necessarily ad hoc in nature in differing frameworks, levels and standards, and can devolve by default to an individual who, whilst well-motivated, may lack the skills and training to properly perform the function, particularly when the vulnerable adult may be in crisis.’

The DHSC is required to respond to the report by 21st May, either setting out actions taken or proposed in light of the issues raised, or explaining why no action will be taken.

Image: AJ Garcia