Joanita Nalubowa
PFD Report
All Responded
Ref: 2024-0453
All 1 response received
· Deadline: 8 Oct 2024
Coroner's Concerns (AI summary)
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in placement decisions.
View full coroner's concerns
Please see Box 4, above.
The evidence at the Inquest was that this situation is not uncommon, with those detained under the MHA not infrequently having social circumstances such that their historical place of residency is, for whatever reason, deeply inappropriate (or even dangerous). It should be noted that section 117 Mental Health Act 1983 did not apply. I am concerned that the rigidity and lack of flexibility in the criteria, coupled with the evidence this is a not uncommon phenomenon, gives rise to a risk of future deaths in cases which do not meet the threshold for aftercare under s.117.
Consideration should be given to giving decision makers greater latitude / discretion or the power to apply common sense, in circumstances where (a) it is foreseeable that rigid adherence to criteria will lead to personal injury (including psychiatric injury) and/or serious emotional harm (b) there is an obvious alternative solution, such as accommodation near family.
The evidence at the Inquest was that this situation is not uncommon, with those detained under the MHA not infrequently having social circumstances such that their historical place of residency is, for whatever reason, deeply inappropriate (or even dangerous). It should be noted that section 117 Mental Health Act 1983 did not apply. I am concerned that the rigidity and lack of flexibility in the criteria, coupled with the evidence this is a not uncommon phenomenon, gives rise to a risk of future deaths in cases which do not meet the threshold for aftercare under s.117.
Consideration should be given to giving decision makers greater latitude / discretion or the power to apply common sense, in circumstances where (a) it is foreseeable that rigid adherence to criteria will lead to personal injury (including psychiatric injury) and/or serious emotional harm (b) there is an obvious alternative solution, such as accommodation near family.
Responses
Action Planned
The MHCLG will write to the local authorities concerned to remind them of their statutory duties, and the government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. (AI summary)
The MHCLG will write to the local authorities concerned to remind them of their statutory duties, and the government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. (AI summary)
View full response
Dear Mr Lambert,
RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO THE DEATH OF JOANITA NALUBOWA
Thank you for your letter and investigative report dated 13 August 2024 into the tragic death of Joanita Nalubowa, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
First, I want to express my sincere condolences to Ms Nalubowa’s family and friends. I was very sorry to read about her death, and the situation and circumstances that led to her tragically taking her own life. It is vitally important that vulnerable individuals are provided with the support and care they deserve. As a victim of domestic abuse experiencing mental health challenges, from the evidence provided and the information in your report, it appears that at a crucial time, Ms Nalubowa’s needs were not met and that the system failed and let her down.
I have provided more detail below on the relevant frameworks that should have been in place to support Ms Nalubowa to access homelessness support or social housing. From the evidence provided, it appears that these frameworks failed Ms Nalubowa in practice. I will be writing to the local authorities concerned to remind them of their statutory duties in this regard. I will reiterate my expectation that local authorities should place a high level of importance on using the discretion available to them when assessing applications for homelessness support or social housing, particularly for vulnerable people such as Ms Nalubowa.
In addition, the Government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. This will ensure all local authorities must provide this exemption.
Below I set out more on the specific aspects and explain in more detail the steps I am proposing to take to ensure that the tragic situation that Ms Nalubowa faced is not experienced by others.
Matter of Concern 1: Aftercare support where section 117 Mental Health Act 1983 does not apply
My Department is committed to continuing to work with the Department of Health and Social Care (DHSC) to ensure the effective interaction between health and housing support services. On 6 November, DHSC introduced a Mental Health Bill to reform the existing Mental Health Act and make it fit for the 21st Century, improving patients’ experiences of hospital and mental health outcomes (Better care for mental health patients under major reforms - GOV.UK). The Bill will improve decision making around detention, discharge, care and treatment. Discharge processes will also be reviewed more broadly and will include a safety management plan for the patient, to keep themselves and others safe.
Matter of Concern 2: Housing Support
My Department is responsible for the statutory frameworks that govern both homelessness and access to social housing. The Housing Act 1996 Part 7 sets out the duties local housing authorities have towards homeless households, and the Housing Act 1996 Part 6 sets out social housing provision.
Based on the evidence provided, there are several aspects of these legislative frameworks that may have been of relevance to Ms Nalubowa’s experience of seeking accommodation support.
Homelessness – Local Connection
As set out at S184(2) of the Housing Act 1996, when a local authority makes inquiries to determine whether an applicant is owed homelessness duties, part of these inquiries can be to establish if an applicant has an existing local connection.
In instances where the duty has been accepted by an authority, but the applicant does not have a local connection with that authority, the authority may refer the applicant to a local authority where the applicant does have a local connection. However, the ability of a local authority to refer is a power, rather than a duty, and so it is at the authority's discretion to make a referral.
Importantly, as set out within the S198 of the Housing Act 1996, certain conditions must be met in order for a referral to be made, one of which is that the person would not be at risk of domestic abuse in the area where the referral would otherwise be made.
In circumstances where an applicant is at risk of domestic abuse in a certain area, which as suggested in your report may have been a factor that led Ms Nalubowa to seek support in London rather than Stockton, an authority cannot refer them to an area where they would be at risk (S198(2)(c), and must instead accept the homelessness duty themselves.
The statutory Homelessness Code of Guidance is also clear that local housing authorities should enquire whether the applicant would be at such a risk, and stipulates that authorities should not impose a high standard of proof when making its decision (Local connection and referrals to another housing authority – Homelessness Code of Guidance – GOV.UK.) From the evidence provided, it appears that in Ms Nalubowa’s case the legislation may not have been applied as intended.
Social Housing – Access and Priority
Local authorities have the power to manage their own allocation scheme and by law must give certain people ‘reasonable preference’ (priority) for an allocation of social housing. This includes people who are homeless, or who need to move for medical or welfare reasons (including those suffering from mental illness). Local authorities can also give ‘additional preference’ (high priority) to those in the reasonable preference categories that have very urgent housing needs. Statutory guidance is clear that local authorities should consider giving additional preference to those escaping domestic abuse.
Guidance is also clear that local authorities have powers to exempt victims of domestic abuse from any local connection tests to determine who qualifies for an allocation of social housing and should consider the needs of those that require support to rehabilitate and integrate back into the community.
From the evidence provided, it appears that the frameworks governing social housing and homelessness failed Ms Nalubowa in practice. I will be writing to the local authorities concerned to remind them of their statutory duties in this regard and to ensure awareness of the flexibilities provided. I will reiterate my expectation that local authorities should place a high level of importance on using the discretion available to them when assessing applications, particularly for vulnerable people such as Ms Nalubowa.
The Prime Minister also announced on 24th September that the Government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. This will ensure that all local authorities must provide these exemptions.
I also want to reiterate the Government’s commitment to working with councils, partners and other stakeholders to support vulnerable groups, including those who are vulnerable due to mental illness. Nobody should feel afraid in their own home and we are committed to halving violence against women and girls in a decade, and we will do everything in our power to achieve this and use every lever across government. As part of this work, and learning from Ms Nalubowa’s tragic circumstances, we are determined to explore what more can be done to reduce barriers to access social housing so that we can provide help for those who need it most.
Thank you for bringing the tragic death of Ms Nalubowa to my attention and once again, I wish to express my sincere condolences to Ms Nalubowa’s family and friends.
RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO THE DEATH OF JOANITA NALUBOWA
Thank you for your letter and investigative report dated 13 August 2024 into the tragic death of Joanita Nalubowa, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
First, I want to express my sincere condolences to Ms Nalubowa’s family and friends. I was very sorry to read about her death, and the situation and circumstances that led to her tragically taking her own life. It is vitally important that vulnerable individuals are provided with the support and care they deserve. As a victim of domestic abuse experiencing mental health challenges, from the evidence provided and the information in your report, it appears that at a crucial time, Ms Nalubowa’s needs were not met and that the system failed and let her down.
I have provided more detail below on the relevant frameworks that should have been in place to support Ms Nalubowa to access homelessness support or social housing. From the evidence provided, it appears that these frameworks failed Ms Nalubowa in practice. I will be writing to the local authorities concerned to remind them of their statutory duties in this regard. I will reiterate my expectation that local authorities should place a high level of importance on using the discretion available to them when assessing applications for homelessness support or social housing, particularly for vulnerable people such as Ms Nalubowa.
In addition, the Government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. This will ensure all local authorities must provide this exemption.
Below I set out more on the specific aspects and explain in more detail the steps I am proposing to take to ensure that the tragic situation that Ms Nalubowa faced is not experienced by others.
Matter of Concern 1: Aftercare support where section 117 Mental Health Act 1983 does not apply
My Department is committed to continuing to work with the Department of Health and Social Care (DHSC) to ensure the effective interaction between health and housing support services. On 6 November, DHSC introduced a Mental Health Bill to reform the existing Mental Health Act and make it fit for the 21st Century, improving patients’ experiences of hospital and mental health outcomes (Better care for mental health patients under major reforms - GOV.UK). The Bill will improve decision making around detention, discharge, care and treatment. Discharge processes will also be reviewed more broadly and will include a safety management plan for the patient, to keep themselves and others safe.
Matter of Concern 2: Housing Support
My Department is responsible for the statutory frameworks that govern both homelessness and access to social housing. The Housing Act 1996 Part 7 sets out the duties local housing authorities have towards homeless households, and the Housing Act 1996 Part 6 sets out social housing provision.
Based on the evidence provided, there are several aspects of these legislative frameworks that may have been of relevance to Ms Nalubowa’s experience of seeking accommodation support.
Homelessness – Local Connection
As set out at S184(2) of the Housing Act 1996, when a local authority makes inquiries to determine whether an applicant is owed homelessness duties, part of these inquiries can be to establish if an applicant has an existing local connection.
In instances where the duty has been accepted by an authority, but the applicant does not have a local connection with that authority, the authority may refer the applicant to a local authority where the applicant does have a local connection. However, the ability of a local authority to refer is a power, rather than a duty, and so it is at the authority's discretion to make a referral.
Importantly, as set out within the S198 of the Housing Act 1996, certain conditions must be met in order for a referral to be made, one of which is that the person would not be at risk of domestic abuse in the area where the referral would otherwise be made.
In circumstances where an applicant is at risk of domestic abuse in a certain area, which as suggested in your report may have been a factor that led Ms Nalubowa to seek support in London rather than Stockton, an authority cannot refer them to an area where they would be at risk (S198(2)(c), and must instead accept the homelessness duty themselves.
The statutory Homelessness Code of Guidance is also clear that local housing authorities should enquire whether the applicant would be at such a risk, and stipulates that authorities should not impose a high standard of proof when making its decision (Local connection and referrals to another housing authority – Homelessness Code of Guidance – GOV.UK.) From the evidence provided, it appears that in Ms Nalubowa’s case the legislation may not have been applied as intended.
Social Housing – Access and Priority
Local authorities have the power to manage their own allocation scheme and by law must give certain people ‘reasonable preference’ (priority) for an allocation of social housing. This includes people who are homeless, or who need to move for medical or welfare reasons (including those suffering from mental illness). Local authorities can also give ‘additional preference’ (high priority) to those in the reasonable preference categories that have very urgent housing needs. Statutory guidance is clear that local authorities should consider giving additional preference to those escaping domestic abuse.
Guidance is also clear that local authorities have powers to exempt victims of domestic abuse from any local connection tests to determine who qualifies for an allocation of social housing and should consider the needs of those that require support to rehabilitate and integrate back into the community.
From the evidence provided, it appears that the frameworks governing social housing and homelessness failed Ms Nalubowa in practice. I will be writing to the local authorities concerned to remind them of their statutory duties in this regard and to ensure awareness of the flexibilities provided. I will reiterate my expectation that local authorities should place a high level of importance on using the discretion available to them when assessing applications, particularly for vulnerable people such as Ms Nalubowa.
The Prime Minister also announced on 24th September that the Government will bring forward changes to social housing allocations regulations to apply exemptions to victims of domestic abuse from local authority residency and local connection tests. This will ensure that all local authorities must provide these exemptions.
I also want to reiterate the Government’s commitment to working with councils, partners and other stakeholders to support vulnerable groups, including those who are vulnerable due to mental illness. Nobody should feel afraid in their own home and we are committed to halving violence against women and girls in a decade, and we will do everything in our power to achieve this and use every lever across government. As part of this work, and learning from Ms Nalubowa’s tragic circumstances, we are determined to explore what more can be done to reduce barriers to access social housing so that we can provide help for those who need it most.
Thank you for bringing the tragic death of Ms Nalubowa to my attention and once again, I wish to express my sincere condolences to Ms Nalubowa’s family and friends.
Sent To
- Ministry of Housing, Communities and Local Government
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Oct 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 5 February 2021 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Joanita Nalubowa, born in Uganda on 27th May 1990. The investigation concluded at the end of the inquest on 5 August 2024.
On 25th December 2020 Ms Nalubowa suspended herself with a ligature, whilst an inpatient at the St Pancras Hospital in King’s Cross. She was successfully resuscitated but sustained an hypoxic brain injury from which she subsequently died.
The jury returned a conclusion of Misadventure, and found as follows in Box 3:
Death by hanging The medical cause of death was
1a Hypoxic ischaemic encephalopathy 1b Asphyxiation by hanging 1c Severe major depression
On 25th December 2020 Ms Nalubowa suspended herself with a ligature, whilst an inpatient at the St Pancras Hospital in King’s Cross. She was successfully resuscitated but sustained an hypoxic brain injury from which she subsequently died.
The jury returned a conclusion of Misadventure, and found as follows in Box 3:
Death by hanging The medical cause of death was
1a Hypoxic ischaemic encephalopathy 1b Asphyxiation by hanging 1c Severe major depression
Circumstances of the Death
(1) Immediately prior to her detention the Deceased had been living in Stockton in the North of England (near Middlesbrough).
(2) However she was now divorced with few ties to that area.
(3) Moreover, importantly, concerns had been raised that the ex-partner in question was abusive.
(4) The Deceased’s family and support network was in London and not Stockton.
(5) Returning to Stockton was a source of great anxiety for the Deceased. She commented that she would “rather die than return to Middlesbrough [sic]”.
(6) It was clear to treating clinicians that securing the right accommodation was paramount to her mental health prognosis and to her future more generally.
(7) It was clear to treating clinicians that surrounding the Deceased with a positive supportive network of family was crucial in maintaining mental health.
(8) Despite all of the above, the existing framework/rules were such that all London boroughs, correctly applying the relevant criteria, rejected the Deceased’s applications for accommodation in London.
(9) The witness evidence was clear that there was no “discretion” and that London Boroughs and treating clinicians alike were powerless. The Deceased was therefore discharged to Stockton, against her wishes, against medical advice, away from her support network, and to an area where she would have to at best face her demons and at worst be in physical danger. (10) Shortly after being told she was being discharged to Stockton, the Deceased suspended herself using a ligature.
(2) However she was now divorced with few ties to that area.
(3) Moreover, importantly, concerns had been raised that the ex-partner in question was abusive.
(4) The Deceased’s family and support network was in London and not Stockton.
(5) Returning to Stockton was a source of great anxiety for the Deceased. She commented that she would “rather die than return to Middlesbrough [sic]”.
(6) It was clear to treating clinicians that securing the right accommodation was paramount to her mental health prognosis and to her future more generally.
(7) It was clear to treating clinicians that surrounding the Deceased with a positive supportive network of family was crucial in maintaining mental health.
(8) Despite all of the above, the existing framework/rules were such that all London boroughs, correctly applying the relevant criteria, rejected the Deceased’s applications for accommodation in London.
(9) The witness evidence was clear that there was no “discretion” and that London Boroughs and treating clinicians alike were powerless. The Deceased was therefore discharged to Stockton, against her wishes, against medical advice, away from her support network, and to an area where she would have to at best face her demons and at worst be in physical danger. (10) Shortly after being told she was being discharged to Stockton, the Deceased suspended herself using a ligature.
Copies Sent To
Minister of State at the Ministry of Housing, Communities and Local Government
Stockon on Tees Borough Council
Camden and Islington Trust (“CANDI”)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.