The handwritten letter to welfare officials found in the flat of Errol Graham, the Nottingham man who starved to death after his benefits were stopped in 2018, is completely free of the rancour one might expect from a person in his position. Instead, the message, published in the Guardian last week, was a dignified attempt to explain why he needed support. “Sometimes I can’t stand to even hear the washing machine, and I wish I knew why,” Mr Graham wrote. “I think I feel more secure on my own in my own company, but I wish it wasn’t like that.”

Mr Graham was known by the Department for Work and Pensions to have severe mental health problems. But in October 2017 his social security payments were cut off after he failed to attend a fit-for-work test. When his body was found by bailiffs, he weighed four and a half stone. The decision to cut off Mr Graham’s payments, and the way this decision was taken – without notifying his GP, family members, landlord, or social services – are the subject of legal action against the DWP by his relatives. But while the details of the case are shocking, and shaming, what is even more disturbing is that these events were not the result of human error, or DWP malfunction. On the contrary, an official told last year’s inquest into Mr Graham’s death that the department’s guidelines were correctly followed.

No one knows for sure how many deaths are linked to the stopping of benefits payments. The DWP has conducted inquiries into 69 suicides since 2014/15, but in a recent report the National Audit Office pointed to an unknown number of other cases which have not been reviewed. Academics have suggested the number of suicides linked to sanctions could be several hundred. The facts are even more sparse when it comes to people such as Mr Graham, who have died from neglect or illness after losing their incomes.

Thérèse Coffey is the seventh person to fill the role of secretary of state for work and pensions since David Cameron became prime minister in 2010. This revolving-door approach to the leadership of an enormous government department, which would be unthinkable in any other organisation with 84,000 employees, is even less forgiveable when you consider that this is a decade during which the social security system has been entirely overhauled.

It is not an exaggeration to state that the DWP holds the lives of many thousands of the UK’s most vulnerable people in its hands. The coroner at Mr Graham’s inquest rightly described any decision to terminate benefits payments as “momentous”. Yet the DWP’s processes are unreliable and opaque. Ministers have known about benefits-related deaths for a decade, but still cannot say what learning has taken place. The NAO report and a letter from the new work and pensions committee chair, Stephen Timms, set out some clear steps. These should be adopted. They include new guidance with regard to the treatment of vulnerable claimants, a set of standards to determine when a death is investigated, a review process with independent input and transparency around recommendations, and improvement of data overall.

That such arrangements are not already in place is extraordinary when you consider the rigour of the audit regimes imposed on other public-sector institutions such as schools. As the problems of homelessness and rough sleeping also demonstrate, the social safety net, under the Conservatives, has become riddled with holes. Ministers have pledged to “level up”. Yet the evidence shows that the state cannot even catch people as they fall.