Prevention of Future Deaths reports · 2015

Anne Fowler

Regulation 28 report to prevent future deaths, reference 2015-0104, written 19 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Mar 2015
Reference2015-0104
DeceasedAnne Fowler
CoronerAndrew Thompson
Coroner areaBlack Country
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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.  Secretary of State for the Home Office 

1 

CORONER 

I am Andrew Thompson, Assistant Coroner, for the coroner area of Black Country. 

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 20 January 2015 at Smethwick Council House I concluded the inquest into the 
circumstances surrounding the death of Mrs Anne Elizabeth Fowler.   

4 

CIRCUMSTANCES OF THE DEATH 

The deceased died in a house fire. The report of the Fire Investigator stated that 
there was a dust cover over the smoke alarm nearest to the seat of the fire and to 
the deceased, and that this would prevent the smoke alarm from sounding as early 
as it would have had the cover not been there. The cover carried a warning to the 
installer to place it over the smoke detector to prevent exposure to excessive dust, 
and a warning to the occupier to remove it once the property had been cleaned. It 
also stated that the alarm would not function if the cover remained in place. 

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.  –  

The cover was in place. The alarm was as is usual, installed on the ceiling where it 
would be inaccessible to many elderly or other immobile occupiers. 

It was stated that the cover was left in place to protect the alarm from the ingress of dust 
etc following fitting. 

Therefore,  you  may  consider  that  legislation  should  be  enacted  to  require  builders, 
landlords  and  others  to  remove  such  covers,  cleaning  around  the  alarm  where 
necessary, prior to allowing the occupier to take possession. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action.  

7 

YOUR RESPONSE 

1 

[IL1: PROTECT] 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 7 May 2015. I, the assistant 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons and Mrs Fowler’s family.  

 Operations Commander, Head of FRIS/ATF, WMFS HQ 

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 

19 March 2015 

2 

[IL1: PROTECT]

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