We reported last week on the outcome of the inquest touching the very sad death of Matthew Dale, a 43 year old male with multifaceted and complex needs. He had significant learning disabilities, autism, visual impairment and bi-polar affective disorder. Matthew lacked capacity to make decisions for himself and was the subject of DOL (deprivation of liberty) safeguards.

Our Head of Personal Injury and Inquest Law, Gareth Naylor, represented Matthew and his family.

Assistant Coroner for the area of Liverpool and Wirral, Kate Ainge, has now exercised her powers under Regulation 28 of The Coroners and Justice Act 2009 and issued a Prevention of Future Deaths Report.

The Regulation 28 report has been sent to The Secretary of State for the Department of Health and Social Care, the RT Hon Steven Barclay.

The Coroner’s report includes the following:

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

It became clear in the inquest that the commission, funding, assessment and provision of care needs is a complex process involving, particularly as in Matthew’s case, where there are multiple agencies involved due to his own complex and multifaceted needs. In this case it has been established that there was a confusion over the care in how it was funded and expected to be provided, compared to that which was understood to be funded and actually provided on the ground to Matthew. The confusion appears to have arisen over the understanding of a number of care terms and the use of them which has resulted in 2 commissioning agencies and an agency providing the care having differing views about Matthew’s care and that which should have been in place and that which was in place.

A full copy of the report can be found here:


A response must be provided within 56 days of the date of this report, namely by March 23, 2023. The response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise they must explain why no action is proposed.

We will publish details of the response in due course.

Our specialist inquest lawyers fight for the truth, accountability and to try and prevent similar events from occurring again.

If you need any advice regarding an inquest, please call our inquest team on 0113 2845000 or send an enquiry.

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