Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0460, written 24 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 | 24 Oct 2014 |
|---|---|
| Reference | 2014-0460 |
| Deceased | Hilda Cole |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 BEING SENT TO:
1. Welbeing, Greencoat House, 32 St Leonards Road, Eastbourne, E Sussex BN21 3UT
CORONER
| am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South
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 16"" July 2014 | commenced an investigation into the death of Hilda May Cole,
Aged 86 years. The investigation concluded at the end of the inquest on 21*
October 2014. The conclusion of the inquest was Accidental death with Mrs Cole
having died from extensive 3 degree burns to the whole body.
CIRCUMSTANCES OF THE DEATH
Mrs Cole was found dead in her home on the morning of 7th July 2014 by firemen
who had been called to the property. She had died from burning. It is likely that she
had been smoking while sitting on a sofa in her lounge and had dropped a lit
cigarette onto the seat or other material on it.
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. Mrs Cole had one of the pendant alarms supplied by you. She was a smoker
with reduced mobility and there was a risk of fires. At the inquest | heard that
family members were not aware that the system that you provide can be
linked into other alarms such as fire alarms and burglar alarms. If they had
been aware they would have subscribed to the fire alarm system for Mrs
Cole. The family have told me that they have subsequently seen literature on
which these others services do appear. However they wonder if you should
be taking more steps to advise existing service users of the additional
facilities you provide and if new customers are aware of these facilities. |
wonder if this something that you should be pursuing?
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 19"" December 2014. |, 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 Family of Mrs Cole {J West Midlands Fire Investigation and
Staffordshire Fire & Rescue Service.
1am 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 | 24 October 2014
Andrew A Haigh
HM Senior Coroner | }
Staffordshire (South) i Li he
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