Prevention of Future Deaths reports · 2015
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 report | 19 Mar 2015 |
|---|---|
| Reference | 2015-0104 |
| Deceased | Anne Fowler |
| Coroner | Andrew Thompson |
| Coroner area | Black Country |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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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