You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 October 2026. I, the coroner, may extend the period if an appropriate  application is made. 

YOUR RESPONSE

I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations  received to the Chief Coroner for a decision. 
Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 

The names of those who do not respond to PFD reports are regularly published on the  Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. 

William lived in a property owned by Cornwall Council. The decision whether to approve or refuse an adaptation such as a stairlift to Cornwall Council owned property is a matter for  Cornwall Housing Ltd (CHL) under its adaptations policy. CHL is a company set up by  Cornwall Council to manage and maintain its housing stock.   
Adult Social Care (ASC) Therapy assessed William’s functional needs on 7 August 2025  and recommended the adaptation as being urgently required.  ASC drafted and submitted the application for a stairlift on William’s behalf.    
The application to CHL noted that there was a serious risk of William falling down the stairs due to significant issues of mobility and balance together with the fact that William needed to be able to safely access the staircase to fulfil caring responsibilities as sole carer for his  wife who has dementia.  The application also referred to the fact that William and his wife  had lived at the property for 50 years and there was a support network in the locality. In  addition to the risk to life there is also an indication that social services would incur 
significant costs as a result of any refusal of the application due to the need to provide additional social care in the absence of necessary adaptations. 
The terms of the current adaptations policy do not take account of any of these factors.  
There are criteria which require applications for adaptations to be refused in all 
circumstances in which there is under or over occupancy.  Williiam lived in a 3-bedroom  property occupied by he and his wife. This was deemed to be under occupancy and the  application was initially refused on that basis.  At Inquest CHL witnesses maintained that this was the correct decision under current policy.
Therapists within ASC do not consider the CHL policy adequately addresses risk and wider circumstances. 
There are practitioners within CHL who consider the adaptations policy to be flawed. The  court found that on two occasions the stairlift for William’s property had been authorised as an exception to the policy. The evidence from CHL is that these decisions (exceptions being made to policy) were erroneous because there are no exceptions under the terms of the policy.  
The court found that there has been no formal multi agency review of potential risks to life from strict application of current policy. 
ASC and CHL have conducted separate reviews leading to learnings which appear focused on communication rather than policy.  These reviews and learnings have not  addressed the concern of a risk of future deaths from the application by CHL of policy to future cases with similar facts to William’s.