Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0228, written 12 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 May 2014 |
|---|---|
| Reference | 2014-0228 |
| Deceased | Amanda Richards |
| Coroner | Sean McGovern |
| Coroner area | Coventry |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive — Whitefriars Housing 4 CORONER 1am S McGovern, Senior Coroner, for the coroner area of Coventry 2 | 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. 3 | INVESTIGATION and INQUEST | opened an investigation on 13 January 2014 into the death of Amanda Richards, late of 5 Kildare Close, Coventry. | concluded the inquest on 24 April 2014 and returned a conclusion that her death was accidental. 4 | CIRCUMSTANCES OF THE DEATH Ms Richards suffered from Peri-ventricular Leckomalacia and was a wheelchair user. She had live-in carers 22 hours per day. On 3° December 2013 it seems she dropped a cigarette and died in the subsequent fire. The fire occurred while she was alone. 5 | 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. ~ | heard from Fire Investigation Officer Holder that the provision of a domestic sprinkler system would have made the death far less likely. | accept that the provision of such a system throughout your housing stock would be prohibitively expensive but! ask you to consider such provision in special accommodation such as Ms Richards. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 July 20t4. |, 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 (2) SEE (mother) 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 respanse by the Chief Coroner. 12 May 2014 i Senior Coroner S McGovern SuGnvers i 1
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Our Reference whitefriars Your Reference <: SMc.bm.1502.13.Richards Contact Name : HOUSING Contact Number _ Email Date : 2 July 2014 Ms Belinda Mattu The Coroner's Office 9 Little Park Street Coventry Central Police Station Coventry Little Park Street CVv1 2UR Coventry CV1 2JK Dear Ms Mattu Re: Amanda Richards (deceased) — Im | am writing in reply to your letter of the 14 May 2014, received on the 19 May 2014. On the 16 June 2014 etc of Housing and Neighbourhood Services for Whitefriars Housing Group, attended the serious incident review which as you will be aware, was led by the West Midlands Fire Service. All key agencies participated in the incident review, and | understand that the learning outcomes will form the recommendations in the plan to be produced by the Fire Service. The action plan will include specific actions for Whitefriars Housing Group, and we have agreed with others present that all agencies need to work together to better understand the risks and issues surrounding the needs of individual residents in special accommodation. Through those agencies working together we will agree specific actions to be undertaken or works to be implemented to meet the needs of the resident. If through such joint working it is agreed that the provision of a domestic sprinkler system to an individual dwelling is the appropriate action to be taken then | confirm that Whitefriars Housing Group would commission and pay for the installation. | can also confirm that such works would be carried out without delay once the course of action had been agreed. email; info @whitetrlarshousing.co.uk www.whitefriarshousing.co.uk Whitefriars Housing Group Limited a chantable, industrial & provident sociely Registered no: 30092R, Registered Office: 9 Little Park Street, Coventry, Warwickshire CV1 2UR Chairman: Mick Rawson RESPECT Fe. aN Group Chief Executive: Pat Brandum MCIH RY hoe ed A full list of board members and direclors Gherespect Get respect INVESTOR INPROMLE irvatter Ir exeationee is available from the registered office | trust the above satisfactorily responds to the Regulation 28 report, but if you should require any further information please do not hesitate to contact me. Yours sincerely Simon Kimberley Executive Director, WM Housing Group
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