HEREFORDSHIRE Council has admitted failings after a homeless man was found dead in his tent beside the river Wye.

Sam Malcolm Taylor, who had suffered mental health issues and attempted suicide on previous occasions, was found dead in his tent beside the river Wye by members of the public, and an investigation was opened into his death by the coroner in November 2022, with a narrative conclusion recorded at his inquest in June 2023.

A note found with him said he would feel suicidal if he returned to the tent after a hospital stay.

In a Prevention of Future Deaths report sent to Herefordshire Council, coroner Mark Bricknell said that a prevention duty was owed to Mr Taylor and that, due to a council communication failure, contact was not made with him or those with whom he had approved contacts prior to his death.

Herefordshire Council said Mr Taylor had been at risk of becoming homeless on his initial contact with the council on July 6, 2022, during which he had told the duty officer that he was required to leave his accommodation on July 11, 2022, and that it accepted that a prevention duty was owed to him.

A case and an application for housing was opened, but was not progressed in a timely manner. Had it been correctly triaged, the council said, it would have been allocated to an officer who would have taken all reasonable steps to prevent Mr Taylor becoming homeless.

A fundamental review of the council's housing responsibilities, services, resources, and management was carried out in 2023, the council said, and its recommendations have led to a comprehensive implementation plan being developed.

The report also said evidence suggested that Mr Taylor would have met the threshold for vulnerability set out in the Housing Act 1996, but the failure to progress the application resulted in this never being established.

The council said homelessness vulnerability tests were not carried out at the initial interview, as he was not homeless at that point, and that subsequent events and additional information then unknown to the council suggest he was more vulnerable than first understood.


"This appears to be in part owing to his admission into hospital on July 7, 2022," the council said.

"The details and the reason for his admission to hospital, which happened after his initial approach to the council, were not subsequently shared with the council."

His case was not triaged until July 26, and was allocated to a housing solutions officer on August 3, the council said.

"Sadly this was all too late as Mr Taylor passed away on or prior to July 17, 2022," the council said.

The council said their implementation plan includes ensuring processes are robust and working more proactively with partners, particularly around duty to refer obligations, and that had they been aware of his hospital admission, it was likely his case would have been reviewed and a vulnerability test undertaken.

The coroner had also said a system for identifying process failure should be in place and effective.

The council said it could confirm that a system for identifying any process failure is now in place and operating, covering regular supervision of individual officers, daily management oversight of the relevant system, and weekly reviews of each case to ensure they are being progressed in a timely manner.

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