The Housing Ombudsman has found severe maladministration following the death of a resident who took his own life following long-running mental health issues.

The ombudsman determined that social landlord Clarion’s lack of consideration of the resident’s vulnerability when handling his complaints about noise led to the resident suffering over a nine-month period.

In the same month the resident first reported the noise issues, which were related to wooden flooring above and children jumping, the resident attempted an overdose, blaming it on the noise nuisance he was suffering. Despite the landlord recording vulnerabilities for the resident, it did not tailor its responses effectively.

Last year, the ombudsman published its Spotlight report on the handling of noise nuisance, raising concerns over the handling of noise-related complaints by landlords. The events in this case predate the report.

In its first response to the resident, the landlord sent a standard ASB letter, agreed to speak to the neighbour and created an action plan for the issue. The neighbour agreed to having carpet fitted, but the resident soon spoke about the little difference this made.

At this time, there was no risk assessment conducted by the landlord.

The resident’s GP wrote to the landlord at this time, but the landlord was unable to find the letter due to a staff member leaving their post.

But from this time, two months after the initial reporting of the noise nuisance, a tenancy sustainment officer had weekly contact with the resident. In the same month, the landlord issued its stage one response which acknowledged the issues and used the weekly contact as an opportunity for updates regarding the complaint.

The landlord said it would not install sounds monitoring equipment due to the Covid-19 lockdown occurring at the time, which was not a reasonable position to take during this time as whilst there were still some restrictions in place, government guidance stated that landlords could carry out repairs and safety inspections.

When the resident filed two more noise reports, he was once again sent the standard ASB letter he was sent months previously. Over the course of four months, the resident completed 18 noise reports and noise recordings were sent to the landlord but due to some software issues, not all were listened to.

A visit to the property by the landlord found “considerable transmission of both noise and movement from the flat above into the resident’s flat” but nothing more was done.

With issues still ongoing, the mental health team expressed concerns to the landlord about the resident. Throughout the complaint the resident himself complained of worsening mental health including anxiety and depression, stressed and not eating or sleeping.

In the month before the resident took his life, the landlord installed some sound monitoring equipment for a short period before removing it and taking no further action. It also did not act on his rehousing request. Ten days before the resident ended his life, the landlord closed the case.

The ombudsman’s report notes that at the coroner’s inquest that, whilst the resident did not leave a note of intent, there was a history of overdose by medication because of the noise issue. There was no Prevention of Future Deaths order made for the landlord and the coroner concluded the resident took his own life.

The ombudsman ordered a senior leader in the organisation to write a letter of apology to the residents’ family, as well as for the landlord to self-assess against the Ombudsman’s Spotlight on Noise complaints report.

The ombudsman also ordered the landlord to review its record keeping against the ombudsman’s Spotlight on Knowledge and Information Management report and review its vulnerable resident’s policy paying regard to how it manages reports of non-statutory noise nuisance, including the use of reasonable adjustments.

In its learning from the case, Clarion says it has apologised to the resident’s family, made changes to its automated letters process and have produced an action plan in relation to noise nuisance.

Richard Blakeway, Housing Ombudsman, said: “This is a deeply distressing case.

“It is clear the landlord’s staff have sought to learn lessons following these tragic events and several of its actions reflect the recommendations we made on our Spotlight report on noise nuisance last year.

“While the events in this case precede our Spotlight report, unquestionably this tragic case shows why the recommendations from this are so important for landlords to urgently address.

“When we published our Spotlight report on noise, we were clear that this was a significant issue for the sector after disrepair. The sector needs to take action to ensure that noise transference is treated with the seriousness it requires.

“Unfortunately, evidence across our casework shows that noise can sometimes be pushed to one side but for residents, this is something that can engulf them.

“In this case, the landlord repeatedly failed to apply a considered and tailored approach to the resident, despite a previous attempt to end his life. That should have been a warning but instead the landlord did not go far enough.”

The ombudsman also found maladministration for how the landlord handled the noise aspect of the complaint.

In its learning statement, Clarion said:We offer our heartfelt condolences to the family and an unreserved apology for all shortcomings in the service we provided the resident. We recognise that our communication process should have been far better and we accept the recommendations of the ombudsman with humility.

“The case and actions taken have been reviewed by the senior management team, and our chief customer officer has personally written to the family.

“We continue to make improvements to how we record and act on vulnerability of our residents and we have reviewed our automated letters process to ensure an appropriate response is issued in line with our vulnerability support policy. Our tenancy sustainment and welfare team, who worked with the resident alongside external agencies, also offer advice to our residents and signpost to extra support when required.

“We have also amended our management transfer policy so that includes a broader consideration of risk which better takes into account exceptional circumstances.

“As part of our learning from this case, and in response to the recommendations in the ombudsman’s report published in October 2022, ‘Spotlight on noise complaints: time to be heard’ we have reviewed our approach and produced an action plan to enhance our procedures so that building noise cases of this kind are separated from anti-social behaviour issues. These changes have been rolled out across Clarion.

“Our new complex case action group will ensure record keeping and support is co-ordinated so that prompt action is taken and the resident receives all the services they need.”

The full report can be found here.