Callum Hargreaves

I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly.

On 22/5/25, I concluded the inquest into the death of Callum James Hargreaves who died on 20/1/24 at the age of 32. I recorded the cause of death as 1a) Multiple Injuries. I recorded a conclusion that Callum died from suicide.

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, I found it was more likely than not that Callum had  jumped or fallen from the cliffs with the intention of ending his own life.

During the course of the inquest, 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. I accepted independent expert evidence that the mental health act  assessment had been thorough and appropriately concluded there were  no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term  admissions to manage a period of crisis in a patient presenting with  complex PTSD/EUPD, that was not indicated here. It was identified that  the rationale for reaching that decision was not recorded in the notes.  This is a matter I have taken up separately with those responsible for the AMHP. The MATTERS OF CONCERN relate to the arrangements made around Callum’s discharge and, in particular, safety planning. 1) It was accepted in evidence that, owing to the decisions made by  Callum, there were only limited options available to the clinicians.  Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected.  Additionally, the possibility of prescribing additional Diazepam was  correctly discounted once it became evident Callum was already  sourcing illicitly more than could be prescribed safely. 2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be  detained and was safe. There was no evidence that this decision  by Callum was explored or tested by the clinicians – instead it  simply appeared to have been accepted by the clinicians without  further enquiry. The independent expert was of the view that in a  situation like this, where the assessing team had very few ‘levers’  available to it, Callum’s mother was potentially one that could and  should have been explored further. It was noted that GMC guidance allows for further enquiry,  specifically that

1. If an adult patient who has capacity to make  the decision refuses to consent to information being disclosed that

you consider necessary for their protection, you should explore  their reasons for this. It may be appropriate to encourage the  patient to consent to the disclosure and to warn them of the risks of refusing to consent. It was noted that the Nearest Relative’s details appeared not to  have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP.

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.