Elizabeth Aurora Kerr

Date of report	18 Oct 2013
Reference	2013-0276
Deceased	Elizabeth Aurora Kerr
Coroner	Nigel Meadows
Coroner area	Manchester City
Category	Product related deaths
Source	judiciary.uk record · original PDF
Responses published	none published

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

This report is made under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.

Recipients
This report is being set to:

e The Rt Hon Mr E Pickles MP, Secretary of State Communities and Local
Goverment (CLG)

e The Rt Hon Mr E. Davey, MP, Secretary of State for Energy and Climate
Change (ECC)

e The Chair and The Chief Fire Officer, Greater Manchester Fire and Rescue

Service

The Association of Chief Fire Officers

The HSE

The Chief Executive of OFGEM

National Grid — Transco

GS Hails Limited

The All Party Parliamentary Gas Safety Group

Coroner

| am Nigel Meadows, H.M. Senior Coroner for the area of Manchester City.

Coroner's legal powers

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Investigation and Inquest

On 8 December 2008 | commenced an investigation into the death of ELIZABETH
AURORA KERR, aged 76. The investigation concluded at the end of the inquest
heard by a jury on the 25 September 2013.

The cause of death was found to be:
ta Carbon Monoxide Poisoning
1b
1c
2 Cardiac Enlargement

The conclusion of the inquest was a Narrative Conclusion comprising of the following
answer to question 3 on the Record of Inquest and a number of separate questions
were asked and answered by the jury.

1. During the early hours of 5" December 2008, there was a boiler malfunction at the
premises of the Royal Bank of Scotland at the junction of Palatine Road and
Lapwing Lane, West Didsbury. This caused a released of large amounts of carbon
monoxide gas into the atmosphere. This found its way to Flat 4 within the properly
by indeterminate routes. The probably source of this carbon monoxide release was
the malfunction of the boiler in the basement of the building. The Fire Service
attended the incident from 6.24am. Efforts were made from 6.30am to identify and
rouse any occupants within the building. These efforts were unsuccessful. The
residential areas of the first and second floors of the building were not entered. At
8.20am the Fire Service considered that there was no further need for their presence
and left site. At around 1.30pm] awoke in a confused state and found his
mother, unclothed and slumped over the toilet. He was unable to rouse her. David
rang his brotherf§in Exeter, who recommended contacting the emergency
services immediately. The Fire Service had already been recalled to the bank at
1.15pm, having been called out separately. An ambulance arrived at 1.45pm. After
members of the Fire Service had brought Mrs Kerr to the ambulance, attempts were
made to revive her. An ECG was carried our and Mrs Kerr was diagnosed as being
in a state of ventricular fibrillation. Her heart was quivering. Cardio-pulmonary
resuscitation was also administered and the ambulance crew attempted to warm her.
They then conveyed Mrs Kerr to Manchester Royal Infirmary, where she was found
to have a carboxy-haemoglobin level of 41.3% and a temperature of 25.9 celsius.
These levels are consistent with a significant exposure to carbon monoxide. Mrs
Kerr died from the effects of carbon monoxide poisoning, with cardiac enlargement
as a contributory factor, at 3.30pm in Manchester Royal Infirmary.

Whilst the jury has had to be objective in its deliberations, we would like to extend
our sympathy to Mrs Kerr's family.

2. Between approximately 07.00 hours and 07.30 hours on the 5 December 2008,
did the incident commander task any fireman with attending the flats and removing
any occupants found? Yes

3. If you answer yes to question 2: did the requirements of the task include forcing
an entry, as necessary? No

4. If you answer no to question 2: should the incident commander have tasked any
fireman with attending the flats and removing any occupants found and forcing an
entry, as necessary, based upon the information available to him and his
understanding of the risks at that time? Not applicable

5. Would the deceased have survived if she had been found and removed from her
flat before approximately 07.30 hours? Yes

Circumstances of death

1. The deceased and her adult Son lived at Flat 4, 35 Ballbrook Road, Didsbury,
Manchester, which was on the second floor of a building. This was rented
accommodation. The ground floor was occupied by a branch of RBS Bank Plc. The
ownership of the building changed in 2005 to a private company. The whole building
was bounded on three sides by roads. Access to the bank via the Lapwing Lane
entrance. The side of the building fronted onto Palatine Road. Access to the flats
was via Ballbrook Avenue. Sometime during the early hours of the morning of 5
December 2008 the gas boiler in the basement of the Bank which provided heating
to the ground floor malfunction and produced large amounts of Carbon Monoxide
(CO) and aiso steam and heat. The probable cause of this was a valve sticking open
and that fault would not have been picked up by routine maintenance.

2. The boiler had an exhaust flue which was found to be incomplete when examined
later in that the internal piping did not go all the way to the external vent. No audible
Carbon Monoxide (CO) alarms had been installed in either basement boiler room,
the ground floor of the bank or any of the flats above

3. At about 05.30 a courier making a delivery to the premises was able to gain
access to the main customer area and noticed that it was full of steam and was very
hot with a lot of condensation. In turn he alerted his control and this triggered a visit
from a security guard from G4S to visit the premises. Something was clearly very
wrong and the Fire Service was called.

4. At 06.21 the first Fire Engine arrived and the commander of that appliance, who
was a Watch Manager, became the incident commander (IC). Very shortly after
arriving the IC and the G4S security guard entered the main doorway of the bank
and only went a few steps inside. It was clear that there was a lot steam reducing
visibility to a few yards plus a lot of condensation. There was also a strange smell
but no smoke. There was a metallic buzzing noise and very quickly the IC began to
consider that the cause may well be a malfunctioning boiler. After exiting the
premises he came to the conclusion that there was no actual fire but that a GMFRS
response was necessary. He instructed one of his Fire Fighters to set up and
operate a positive pressure ventilation fan (PPV) in the front doorway of the bank
main entrance. This was used in an attempt to cool and ventilate the premises and
improve visibility. Ideally he would have wanted to have an exit point for any
fumes/vapour but that was not possible. This was an adaption of the use of PPV.
The IC also instructed two other Fire Fighters to enter the premises wearing
breathing apparatus to see if they could provide any further information. They went

down to the basement and into the boiler room but did not report back anything
significant. This obviously occurred over some time.

5. In chronological terms at 06.24 a second Fire Engine arrived commanded by a
Fire Officer of the same rank as the incident commander. | will refer to him as WMX.
They were both very experienced and had worked together many times before.
WMx did what he described as a 360 reconnaissance of the building and came to
the view that he was dealing with purely commercial premises. He had gone up to
the main entrance door to the flats on Ballbrook Avenue and had pushed four
buttons on the left hand side of the door frame more than once. He did not notice
that one of them actually said “Kerr Flat 4”. It was dark and nor did he notice there
was a cat flap in the door or that there were 3 pints of milk on the door step which
the evidence established had been delivered at about 06.00 that morning. He
reported back to the IC that they were dealing with purely commercial premises.

6. However, he did notice a light switched on on the second floor on the Palatine
Road side of the premises but he did not mention it to the IC because he thought it
would have been obvious to all present. This was actually Mrs Kerr’s bedroom. One
of the Fire Fighters who also went around to the rear metal fire escape which only
went to a first floor level noticed steam which he described as exhaust fumes coming
out of a vent which appeared to be similar to that which was coming out of the open
front door to the bank. Neither the IC nor any other Fire Fighter who attended the
incident noticed the light.

7. The IC knew about the main properties of CO in that it was a toxic, odourless,
colourless, combustible gas which can be produced as part of incomplete products
of combustion. He made a request for a GMFRS Combustible Gas Indicator (CGI) to
be brought to the scene by the duty GMFRS HAZmat Officer. However, a National
Grid - Transco (Transco) engineer arrived and he had his own CGI. This was
calibrated to detect Methane but the IC decided to ask him to use his rather than the
GMFRS version. The evidence established that this was entirely appropriate. The IC
spoke briefly to the HAZmat Officer.

8. At about 07.00 the IC and the Transco engineer entered the bank main foyer but
were not wearing breathing apparatus. The latter used his CGI to monitor the
atmosphere and assess what is known as the lower explosive level (LEL) of any
gases present. The evidence showed that there was a significant misunderstanding
and breakdown in communication between them. At the top of the stairs leading to
the basement the IC was adamant that he was told that the LEL had been recorded
as 20% and that was the level at which Transco would recommend evacuating the
premises. Prior to this it had been lower than 5%. However, the Transco engineer
was equally adamant he had said no such thing and only commented that if it
reached 20% they would have to consider leaving but that the levels were less than
5%. He did say that he wanted to leave immediately because the smell and
atmosphere were intolerable for him. Neither experienced any CO poisoning
symptoms. On leaving the bank the IC also learned for the first time from an RBS
key holder member of staff that there were flats above and one of them may be
occupied. The IC decided on the basis of what he understood to be a LEL of 20%
and possible residential occupation that he would task WMxX to go to the flats and if
anyone was in them, to get them out. At that stage he considered that there was a

risk of explosion. He said that is what he told WMX to do. The PPV was re-activated
and this had certainly helped to cool the premises and improve visibility. By this time
the Transco engineer had also decided to cut off the gas supply to the bank and the
gas boiler service engineer who had recently worked on the boiler had also arrived.
A cordon was set up around the bank.

9, Regrettably, another significant breakdown in communication occurred and WMX
was adamant that he was not told to do this. On the other hand the IC was equally
adamant that he had given such an instruction. In the event WMX did return to the
flat entrance area together with another Fire Fighter and went up a rear fire escape
to the first floor level and knocked and banged on doors. No one responded but he
was doing this not in compliance with any instruction or awareness of any risk of
explosion but simply to advise any occupants that the Fire Service were there by
way of reassurance.

10. By about 07.30 the gas supply had been disconnected and in the IC’s mind the
emergency situation had passed. He recollected that WMX had returned saying in
effect that he could not get find anyone. The IC also allowed the gas boiler engineer
into the premises to isolate and make safe the boiler. The whole incident was
winding down and by about 08.20 the IC decided that the Fire Engines could leave.
The HAZmat officer had attended out of curiosity because he had never known of a
LEL of 20% before. Approaching 09.00 RBS staff were arriving and during the
morning several of the staff became concerned for the welfare of Mrs Kerr because
they saw the milk on the door step and this was unusual because she always took it
in. Their attempts to ring Mrs Kerr's doorbell were also unsuccessful. By about 13.00
they were so concerned that they phoned 999. At about the same time coincidentally
Mrs Kerr’s adult son who also lived in the premises awoke and felt very unwell. He
had vomited and was very disorientated. He found his Mother unconscious and
naked in the bathroom. In his confused state he phoned his brother who told him to
phone 999 and he did so. He was asked to make his way down and open up the
front door. On doing so he was met by attending Police officers and paramedics and
immediately treated. Fire Fighters wearing breathing apparatus went to the second
floor flat and rescued Mrs Kerr. A Police Officer and a Fire Fighter who were not
wearing breathing apparatus entered the flats through the front door and had gone
up a few steps felt the effects before feeling unwell and had to leave. The evidence
suggested the atmosphere in the stairwell inside was toxic. No Fire Fighter who
attended the premises at any time on the 5 December 2008 had any personal
protective equipment CO alarm.

11. The medical evidence established that she had had a cardiac arrest minutes
before she was found at about 13.45 and the jury concluded from all the evidence
heard that had she been found by about 07.30 she probably would have survived.
She and her son must have been rendered unconscious by about 06.30.

12. Mrs Kerr and her son were taken to the Manchester Royal Infirmary and
advanced life support treatment and CPR was given to her. Very shortly after she
arrived she had a Carboxyhaemaglobin test, which showed she had a level of
41.3%. This meant that she must have been breathing contaminated air for a
consistent period until she was found. She was also profoundly hypothermic. A
couple of hours later her son had a test which showed his level to be 10% which

meant that it must have been much higher whilst he was in the flat. Despite all
appropriate treatment Mrs Kerr could not be resuscitated and she was pronounced
dead at 15.30. Her son survived.

13. Post incident investigations ruled out any of her domestic appliances being
responsible for the CO and that its probable source was from the boiler in the
basement. It had managed to find its way from the basement to the second floor.
The precise route or routes of fume migration could not be established. It was noted
that the boiler flue piping to an outside vent was incomplete and hypothetically this
could have allowed fumes to penetrate the brickwork and fabric of the building. It
was also established in a subsequent test that water vapour could pass from the
ground floor to the first floor through the ceiling and floor boards. Even though the
water vapour could not pass into the second floor rooms in this test this could be
explained by the fact that it would necessarily cool as it travelled and it was heavier
than air so had quite different properties to CO. It was also possible that the fumes
could have made their way outside the building and penetrated a vent in Mrs Kerr's
bathroom.

14. It was understood that within the current financial year GMFRS will be acquiring
CG! meters for all their Fire Engines.

Coroner’s concerns

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

The matters of concern are as follows:

1._ All Party Parliamentary Gas Safety Group (APPGSG):

All the recommendations of the All Party Parliamentary Gas Safety Group
(APPGSG) Reducing death by Carbon Monoxide Report of 2011(copy attached)
have not been adopted or enacted. The APPGSG should consider undertaking a
review of progress made in the 2 years since the report.

2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential

movement of CO within a building from its original source and how it can penetrate
and move within it. The HSE could provide more information on its web site and
provide specific guidance or warnings. There is no HSE guidance to landlords and
letting agents as to what independent validation has taken place of the gas and other
fuel safety equipment provided in rented property may be appropriate. Such
information could also be disseminated to and within all Fire and Rescue Services.

3. The Role of Fire and Rescue Services in Carbon Monoxide Safety.
The Fire and Rescue Services currently have no statutory role in Carbon Monoxide

safety, regulation and enforcement. This could be reviewed and considered by the
Department for Communities and Local Government. It is appreciated that this is far
from straight forward and wider issues would need to be taken into account. For

example Fire and Rescue Services have no statutory role in other gases or
substances which cause death. This may require a more detailed analysis and
assessment of issues and complications which may then come to light. In the
absence of a statutory role, and possibly through the Chief Fire Officers Association
“Blue Watch” initiative, Fire and Rescue Services could be encouraged to voluntarily
engage in local and national Carbon Monoxide campaigns. Such campaigns may
benefit from closer working at a local level with relevant CO charities and at a
national level between the Gas Safety Trust, the Gas Safe Charity and the Chief Fire
Officers Association.

3. Ofgem:

They have a public safety role in relation to piped gas safety in that “The regulator
shall, subject to primary duties, carry out functions : in a manner best calculated ....
To protect the public from dangers”. Mrs Kerr died in 2008 and there are about 50
deaths a year from Carbon Monoxide and many more non-fatal incidents. It is
understood that this year alone there have been some 30 deaths, albeit the majority
of them were not a result of leaks from the piped gas system.. However, in view of
the continuing fatalities and incidents, which is a matter of concern , Ofgem and/or
the appropriate government departments may be a need to revisit and recalculate
the regulatory response required by all fuel suppliers and regulators so as to reduce
the avoidable deaths and non-fatal incidents.

4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as

summarised below. It is not clear how gas suppliers define and determine who is a
*vulnerable and priority” customer and how is it established that they have been
offered a free annual gas safety check, and have taken advantage (or not) of such
an offer ? Nor who actually checks what steps a gas supplier takes in practice to
raise the awareness of danger and who judges the reasonability of the steps or who
actually checks what steps other fuel suppliers take in practice to raise the
awareness of danger and who judges the reasonability of the steps?

5. Enforcement and Information:

There is no requirement that in the case of a carbon monoxide death, a clear audit
trail is available of the steps taken by the relevant fuel supplier to ensure the specific
customer in question was aware of the dangers of carbon monoxide poisoning and
the benefits of fitting an audible alarm. At the moment there is no specific information
that fuel suppliers are required to give.

“The licensee must take all reasonable steps to provide, free
of charge, the information required by paragraph 30.6 to each
Domestic Customer at least once each year and must provide it
when requested to do so by a Domestic Customer.

30.6 The information referred to in paragraph 30.5 is
information sufficient to inform each of the licensee’s Domestic
Customers about:

a) the safe use of gas appliances and other gas fittings;
b) the dangers of carbon monoxide poisoning;

c) the benefits of fitting an audible carbon monoxide alarm that
complies with a relevant British or European safety standard;

d) the benefits of gas safety checks; and

e) where to seek advice if gas appliances are condemned as a
result of a gas safety check.

6. The installation , use , maintenance and correct positioning of fixed hard
wired or battery operated CO alarms.
From October 1st 2010 Building Regulations Approved Document J “Combustion

appliances and fuel storage systems’ sets out a number of legal requirements in
England and Wales. For the first time carbon monoxide (CO) alarms were
mandatory “where a new or replacement fixed solid fuel appliance is installed in
a dwelling, a CO alarm should be provided in the room where the appliance is
located.” However Building Regulations only cover the processes used during the
‘building’ or ‘installation’ phases, of a solid fuel appliance and do not have any
power to talk about on-going maintenance processes or the inspection of existing
appliances. CLG could consider whether a safety performance certificate that
included gas safety, along the lines of an energy performance certificate would
promote an improved on-going attitude towards carbon monoxide safety amongst
landlords and lettings agents, and thereby lead to a reduction in carbon monoxide
incidents in rented property. There is at least one national, voluntary, independent
system already available and such a certificate would be a clear demonstration of
compliance with carbon monoxide safety measures.

7. The use and availability of CGI meters by Fire and Rescue Services and
having suitable training in their operation as well as the use of personal
protective equipment CO alarms.

GMFRS did some research in the use of such equipment by all Fire and Rescue
Services. Please see the attached. It is suggested that if all Fire and Rescue
Services carried such equipment on front line appliances and used them on both
emergency responses and preventative work that would reduce the risk of death to
Fire Fighters and the public.

8. The Chief Fire Officers Association “Blue Watch Initiative”

This is a voluntary initiative to be encouraged and supported. It offers an
independent safety validation service for landlords and letting agents.
http://Awww.bluewatch.co.uk/. The investigation established that incomplete flue
piping had not been identified on routine inspection visits despite the regulatory

regime created by the The Gas Safety ( Installation and Use ) Regulations 1988.At
present there is no duty imposed on the owner of a boiler or a gas supplier ( who
makes a profit from the supply ) that in the case of a multi occupancy building to
allow the other occupants , through recognised engineers , to inspect the boiler and
be warned to install CO alarms .

Action should be taken
In my opinion action should be taken to prevent future deaths and | believe you
and/or your organisation have the power to take such action.

Your response

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 13 December 2013. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is proposed.
Copies and publication

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

The Family of the deceased

GVA Grimley

ACE Gas Services
Greater Manchester Police

| have also sent it to:

CO Awareness
CO Gas Safety

lam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the Coroner, at the time
of your response, about the release or the publication of your response by the Chief
Coroner.

Nigel Maeda

N S Meadows Date 18" October 2013
H.M. Senior Coroner — Manchester City area

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