Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0428, written 2 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Oct 2014 |
|---|---|
| Reference | 2014-0428 |
| Deceased | Lexi Branson |
| Coroner | Trevor Kirkland |
| Coroner area | Rutland & North Leicestershire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministry of Justice 2. Defra 3. Leicester City Council 4. Leicestershire Local Safeguarding Board 1 CORONER I am T H Kirkman, Senior Coroner for the coroner area of Rutland & North Leicestershire 2 CORONER’S LEGAL POWERS I 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 On 6th November 2013, I commenced an investigation into the death of Lexi Lavana Branson born on 21st January 2009 . The investigation concluded at the end of the inquest on 9th September 2014. The conclusion of the inquest was that the medical cause of death was facial injuries and external airway obstruction and a narrative conclusion was reached that Lexi died as a result of injuries received in an attack upon her by a dog within her home. 4 CIRCUMSTANCES OF THE DEATH Lexi Branson aged 4¾ years at the date of her death was in the living room in the flat where she lived with her mother. The dog, described as a type of bulldog breed, named Mulan, suddenly attacked Lexi and by the physical presence of the dog’s mouth over the face of the child caused extensive injuries to the neck and face and prevented breathing. 5 CORONER’S CONCERNS During the course of the inquest the evidence, whilst showing that the dog in question was not a type which is prohibited under the Dangerous Dogs Act, 1991, nevertheless, revealed matters giving rise to concern. In 1 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. – I heard evidence that Leicester City Council had a statutory responsibility for collecting stray dogs within its area. A dog named Mulan had been so collected and taken to Willow Tree Kennels in Barrow upon Soar, Leicestershire. The dog had not been reclaimed during the following week and therefore became the property of the Kennels which thereafter was able to sell the dog. The mother of Lexi Branson was looking to acquire a dog. She saw the dog in question advertised by the Kennels upon social media. She visited the Kennels along with Lexi and in the company of an employee of the Kennels was with the dog for some 10 to 15 minutes. She was told that the decision whether to have the dog was left to her. She went away but made contact a couple of days later on 8th October 2013 to say that she would like to have the dog. The Applicant for the dog had said she lived, with her 4-year old daughter, in a flat which had a shared garden. No detailed assessment was carried out as to the suitability of the applicant for the dog in question when taking into account her home and family circumstances nor was any home visit made by the Kennels to assess the home environment. The following concerns became clear as a result of the evidence which I heard: (1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged; (2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments; (3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog. (4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation 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 26th November 2014. I, the coroner, may extend the period. 2 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Lexi’s immediate next of kin and to the Leicester Safeguarding Children Board because the deceased was under 18 years of age. I am 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. 9 2nd October 2014 T H Kirkman 3
2 responses 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.
Animal Welfare Team Area 5D, 17 Smith Square London, SW1P 3JR Date: 11 November 2014 Mr T H Kirkman, MA Senior Coroner for Rutland & N Leics Loughborough Coroner’s Office Charnwood Borough Council Offices Southfield Road Loughborough Leics LE11 2TR Dear Mr Kirkman, Thank you for your letter of 3 October about the inquest into the death of Lexi Branson. We take the issue of dangerous dogs very seriously and were saddened to hear of the death of Lexi. The Government has been taking steps to improve responsible ownership of dogs, including increasing the maximum penalties for allowing a dog to be dangerously out of control and extending the scope of the offence of allowing a dog to be dangerously out of control to all places. We have also introduced early intervention measures through the new anti-social behaviour toolkit that will enable local authority officers or the police to issue warning notices to owners, where such behaviour involves a dog. We realise that these new measures do not fall within the scope of your suggestions to which we have given serious consideration. We understand that re-homing centres need to be aware of any behaviour problems in their dogs. Thousands of dogs are rehomed every year and the vast majority cause no problems for their new owners. Most rehoming centres are responsible and will identify any dogs where the behaviour is a cause for concern or where the owner’s personal circumstances may not suit the dog in question. The problem with trying to apply standards in relation to testing a dog’s behaviour is that it is by no means an exact science. A dog might pass a behaviour test but it would not necessarily be a guarantee that the dog’s behaviour will not be a cause for concern once it is in new surroundings and with a new owner. As I mentioned, most dog re-homing centres take appropriate steps, along the lines you have proposed, to try and prevent such incidents occurring. The Government is determined to reduce dog attacks and appreciates the comments and suggestions you have made. What would be useful at this stage is for the department to explore with larger recognised dog rehoming organisations such as Dogs Trust, RSPCA, Blue Cross and Battersea Dogs & Cats Home to see whether they would be willing to share their rehoming checks with other smaller rehoming centres. We will therefore write to the main dog rehoming centres (explaining the recommendations you have made) and explore ways in which best practice in dog rehoming checks can be disseminated to others involved in this activity. Yours sincerely Head of Animal Welfare
Date: 20 November 2014 Leicester City Council Mr T H Kirkman Senior Coroner for Rutland & North Leicestershire Loughborough Coroner's Office Charnwood Borough Council Offices Southfield Road Loughborough Leicestershire LE11 2TR Dear Mr Kirkman Inquest into the Death of Lexi Branson Thank you for sending a copy of your report following the inquest into the death of Lexi Branson. Firstly on behalf of the City Council can we extend the condolences you passed on to Lexi's family at the inquest. You will appreciate that before amount of effort was given to any possibility in which future deaths might be prevented. evidence at the hearing a considerable You will recall that Leicester City Council's only obligation under law is to look after dogs for the first 7 days of being found as a stray. You will recall that a private kennel, Willow Tree of Loughborough, looked after Mulan in order to allow the Council's obligations in law to be met by an external third party contractor. One option which was covered in evidence was simply for dogs to be euthanised on day 8. The four issues you have raised are potentially wider than matters within the remit of Leicester City Council and accordingly in the absence of national standards it is difficult to understand how Leicester City Council could contribute. Even if any national standards were drafted, we can see no way in which any of the usually charitable small organisations could be compelled to agree to those standards if issued as guidance only. The very disparate and varied nature of the sort of bodies which provide that service across the UK, even aside from legal obligations, possibly explains why each different organisation may adopt its own individual rehoming standards. In part this also covers the fourth "concern" you have raised in your report. We can assure you that as part of our investigation into the preparation of this case, various enquiries were made both of a number of different bodies with similar duties, and other organisations such as Dogs Trust, Birmingham Dog Homes and the RSPCA. We can confirm each body approached had some similarities but also some differences in the systems used. All of the evidence we heard at the inquest would have led anyone to think that Mulan's behaviour was passive. It is perhaps self-evident but worth reiterating that the previous incident and the risk that Mulan's owner perceived after it attacked another dog had not been mentioned when he called us and told the warden (wrongly) that the dog was a stray. Prior details about its history, breed, temperament, reason for being released and any potential for a repeat of that incident might have been helpful to anyone involved in the rehoming process. Without that information, the assessment of the dog can only be based on how it behaved after it was collected. In those circumstances, while of course we understand your concerns, the Council in fact has arguably little or no power in order to prevent such future deaths and can only continue to do its best to ensure that any learning from this tragic case has been conveyed to the current kennel provider acting on its behalf. We do trust that this is of assistance to your enquiries but if we can be of any more assistance at all on this; please do not hesitate to contact me. Yours sincerely Chief Operating Officer LEICESTER CITY COUNCIL City Hall, 115 Charles Street, Leicester, LEl l FZ www.leicester.g ov .uk
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