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, it is more likely than not that Callum has jumped or fallen from the cliffs with the intention of ending his own life.

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. At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20  January 2024. 1) One issue that arose was whether Callum presented with an  imminent and significant risk of harm to justify a short-term  admission into hospital as is provided for in NICE guidance. Ms  Ashton said this was expressly discussed by the clinicians  concerned. It was felt he was likely to be withdrawing and there  were no resuscitation facilities available in Longreach. She also  said the vulnerabilities of others on the ward needed to be  considered all of which contributed to the decision not to detain  Callum in hospital. She accepted that this rationale was not  recorded in the notes. 2) Callum was asked whether he wanted his mother (who he  described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to  involve her should have been explored further. You may feel these omissions should be learned from when  assessments are conducted in the future and, in particular, when  notes of an assessment are subsequently recorded.

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.