A woman prone to self-neglect and living in squalid conditions died on the steps leading to her home after safeguarding concerns were not acted upon, a report has stated.
Miriam Smith-Cox, 60, was found dead at around 2.10pm on the March 4, 2015, at the property in which she lived in Newlyn.
She was found lying on her back on the stairs leading to the front door with a significant head injury.
The report says Ms Smith-Cox, a large lady, was last known to be alive at 5pm on March 3.
The report into her death has just been made public on the Courts and Tribunals Judiciary website and states that Ms Smith-Cox lived in squalid conditions and was known by Cornwall Council social service and the housing association and her GP to self-neglect. The report was written by senior coroner for Cornwall and the Isles of Scilly Emma Carlyon – a ‘Regulation 28 report to prevent further deaths’ due to the concerns she had after overseeing the inquest.
The report reads: “She suffered from mild learning difficulties although not formally diagnosed. On that day her cat was to be taken to the vet/foster placement prior to Ms Smith-Cox being placed in a respite/rehabilitation placement in a residential home while her flat was cleaned and decluttered.
“She had been referred to the Pluss Work Choice Programme in August 2014 by the disability employment advisor for the Job Centre Plus having been on benefits for many years.
“She was assessed as having psycho/social issues at that time which prevented her from accessing the work place.”
During the assessment by Pluss Work Choice, it was stated that programme safeguarding concerns were raised by the employment team manager to social services in December 2014 with regards to the suitability and state of her accommodation which was not acknowledged or acted upon for unknown reasons.
It was not clear the extent to which that neglect/self-neglect played a part in the death as the reason for her fall down the stairs was not established. The cause of death was due to the injuries consistent with her fall down stairs.
Recording an open conclusion to the inquest, Dr Carlyon went on to express a number of concerns.
She noted that the concerns raised were not acknowledged or acted upon and recommended that action should be taken to prevent future deaths.
Dr Carlyon ordered that Cornwall Council adult social services review their safeguarding adult procedures (in particular how concerns are logged, processed and dealt with) and provide her with reassurance that lessons have been learnt with the view to avoiding future deaths.
The Department for Work and Pensions has said that it provided Ms Smith-Cox “extensive and committed assistance”, paid her money to live on and went beyond its remit to try to set up a multi-agency conference with social services.
Pluss added that Ms Smith-Cox left the Work Choice Scheme in February 2015 when it was understood that a social worker was putting together a package for her.
It went on to state that as a result of Ms Smith-Cox’s death staff were reminded of safeguarding policy and their responsibilities in that area.
Cornwall Council has been asked how Dr Carlyon’s recommendations were implemented.