Prevention of Future Deaths reports · 2015

Kenneth Bailey

Regulation 28 report to prevent future deaths, reference 2015-0275, written 14 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Jul 2015
Reference2015-0275
DeceasedKenneth Bailey
CoronerJohn Pollard
Coroner areaManchester South
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: The Chief Fire Officer, Greater Manchester Fire
and Rescue Service

1 | CORONER

| am John Pollard, senior coroner, for the coroner area of South Manchester

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

On 27" March 2015 | commenced an investigation into the death of Kenneth George
Bailey dob 11" December 1950. The investigation concluded on the 9" July 2015 and
the conclusion was one of Accidental death. The medical cause of death was 1a
Smoke Inhalation 11. Lung cancer, cerebrovascular disease, fibrotic lung disease (on
home oxygen).

4 | CIRCUMSTANCES OF THE DEATH “|

The deceased had been diagnosed with lung cancer and was in a very debilitated
condition. He required oxygen at his home to allow daily living. On the 25" March
2015 he was at home smoking a cigarette when he dropped it or the ash from it,
on to a kitchen roll which then ignited leading to a significant house fire. He died
as a result of inhaling significant quantities of acrid smoke.

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. —

During the course of the evidence | was told of the efforts of neighbours and
others to attempt a rescue, which to some extent they were able to do. One reason
for this attempted rescue was because of the time lapse in getting fire appliances
to the scene. | was informed that there is a Fire Station in Mossley, Aston u Lyne,
but this is only manned during very limited opening hours.

I was also informed that there is a significant body of volunteers prepared to act
as local volunteer fire officers.

Because the fire station was not manned, it took approximately 10 minutes for the
fire service to arrive, and whilst this is of course reasonably fast, the local people
felt the response time used to be quicker when the local “station” was open.

If there is a delay in the arrival of the emergency services, there is always the
danger that unqualified people will try to perform a rescue thus placing
themselves in danger of injury or even death.

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 9" September 2015. I, 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 co the Chief Coroner and to the following Interested
Persons namely (partner of the deceased).

| 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 ma

14.7.1 John Pollard, HM Senior Coroner

Responses

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.

Response from Greater Manchester Fire and Rescue Service (PDF)
Your Reference  JSP/KN/00851-2015 Mw

Our Reference PO/GW

Date 3' September 2015 _
SP) A GREATER MANCHESTER
Ce se: , Fle | FIRE AND RESCUE SERVICE
07 SEP 2015 |
Mr. J.S. Pollard LI.B.Hons ; lama
Senior Coroner | ane
H M Coroner - Manchester South ‘=~ CGeederiandhadhairierorsi#enns
Coroner’s Court Service
1 Mount Tabor Street di
Stockport Manchester M27 8US
Telephone 0161 736 5866
SKT SAG Lo re
‘www.manchesterfire.gov.uk

Dear Mr Pollard,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS — KENNETH GEORGE

BAILEY (25' March 2015, 05:51)

| am writing in response to your j ing the inquest into the death
of Mr Kenneth George Bailey of

Before responding to the Report | would like to express and place on record Greater
Manchester Fire & Rescue Authority's deepest condolences to Mr Bailey's family and

friends.

Set out below is the response to the concerns you have raised under Regulation 28 of the
Coroners (Investigations) Regulations 2013. In the reply | have attempted to provide
sufficient information to inform you of the work undertaken by Greater Manchester Fire and
Rescue Service (GMFRS) to ensure that Mossley fire station achieves a sustainable crewing
model that meets the needs of the community. The report is intended to provide information
to assist you in understanding why Mossley Fire Station did not have a ‘Crewed’ fire
appliance available to respond to a fire incident which occurred on the 25 March 2015,
05:51hrs at 19 Brooklands Close, Mossley, OL5 ONJ.

Background:

Mossley Fire Station has gone through a number of significant changes over the last few
years as a consequence of falling demand for its services (Appendix 1) and the financial
constraints placed on GMFRS through budgetary reductions. In response to the financial
climate GMFRS has undertaken a number of restructures, changed the overall response
model to reflect a significant reduction in fire related incidents (Appendix 2) and made
changes to the duty systems to create a more efficient use of resources.

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The current duty system at Mossley, has been in place since November 2013, and is based
on 10 staff comprising of 3 Officers and 7 Firefighters, working 10.5 hour days, 7 days per
week. The night time fire cover for the Mossley area is provided primarily by Ashton,
Stalybridge and Oldham fire stations to give fire cover that meets the published response
standards (Appendix 3), as far as reasonably practicable. The response standards are
based on our current risk modelling and up to the present date (including the incident on the
25!" March 2015) we have achieved our set response standard times for all of the Primary
Fires we have attended during the shift period that Mossley Station does not have a Crewed
fire engine (i.e. the night shift) (Appendix 4).

The current response standards for Mossley’s area are a mix of all risk categories but the
majority of premises fall into category 3 (attendance less than 12 minutes) and risk category
4 (attendance less than 17 minutes).The response standards are published and have been
consulted via our Corporate Plan 2012-2015. Response standards remain a Key
Performance measure for GMFRS and as such are reviewed and published in our Integrated
Risk Management Plan annually.

To meet our response standards GMFRS takes a holistic view to providing fire cover. As
such all of our 40 other stations are considered in the fire cover planning process and where
necessary ‘closing in’ or standby moves are made to ensure standards are met. In addition
GMFRS has agreements with surrounding Fire Authorities to provide mutual assistance and

reinforcement if required.

Although the response standards for Mossley can be met from other surrounding stations
the Fire Authority has determined that it does not wish to close fire stations if at all possible,
despite significant recent financial constraints and budgetary cuts. As such, in 2012 work
commenced on looking at alternative crewing solutions that could provide 24 hour cover but
at the same time were reflective of operational demands and the need for efficiencies.

Following research it was recommended that the way to provide future cover at Mossley
was to develop a new duty system which provided wholetime fire cover through the day and
‘on-call’ or retained cover during the night and weekend periods. The model selected was
based on a similar system which has been in place for a number of years at Marple fire
station, which we describe as ‘Nucleus crewing’

Recruitment Process for ‘On-call’/retained cover:

On call or retained staff are required to meet the same exacting standards as their wholetime
colleagues. As such our tests are based on national occupational standards relating to
fitness, health, dexterity, vertigo, claustrophobia and academic attainment. Additionally to
meet our response standards and thus support our risk modelling, potential candidates need
to live within a four minute footprint of the fire station at which they will provide cover. This
is based on the old standards of fire cover and designed to meet the previous statutory ‘D’
and ‘C’ risk response times of 20 minutes and 8-10 minutes respectively (Source: ODPM,
The Fire and Rescue Service Retained Duty System, February 2005). Evidence has shown
that a minimum of 12 people are required to provide cover to supplement whole time shift
during the night and weekends.

The first ‘on-call’ recruitment process conducted specifically for Mossley was in early 2014.
Of the 20 applicants only three achieved the standards; one of these was subsequently
offered a full time contract by the police and withdrew from the process.

The second retained process was initiated by GMFRS following the death of Mr. Bailey.
Local help and support was given by] who lived next door to Mr. Bailey,
and was one of the rescuers. NF also gathered support of local residents, utilising
social media, and this helped to attract a much higher level of interest.

Initial interest was positive, with approximately 45 people attending an open evening taster
session to acquire knowledge about the role of an ‘on-call’ firefighter. Positive local action
was also provided to increase awareness of the standards required by the means of three
taster sessions, which was open to all residents who were interested in applying.

Of the 45 initial expressions of interest, we received 30 applications, of which 15 people
attended pretest assessments. Of those 15 attendees, 12 successfully passed elements of
the National Firefighter Skills tests. The candidates who did not pass all of the tests were
informed of the improvement required to fully satisfy the tests. The full entrance tests were
programmed for the 27" of July 2015.

Eligibility checks for all applications (including those who did not attend testing), took place,
however, only 6 of the 30 applicants currently met the attendance criteria of living within a
four minute footprint of the station.

In parallel to the campaigns locally we have attempted to attract wholetime firefighters who
currently work for GMFRS to provide ‘on-call’ cover. However, the commitment in terms of
hours, the levels of pay and the current availability to undertake ‘additional hours’ at their
own stations make ‘on-call’ cover a financially unattractive option. Having consulted with
other Fire and Rescue Services (FRS) around the country, it is clear both nationally and
locally that FRS’s are finding the attraction, recruitment and retention of retained/on-call

firefighters to be challenging.

In light of the struggles we have had to recruit sufficient staff that met the required criteria.
GMFRS have recently reflected on the current campaign and an alternative solution has
recently been considered and approved by the Fire Authority. This decision stems from the
fact that despite our efforts and those of the Mossley community up until the 22 of July
2015 we only had 3 viable candidates to put forward to undertake basic training, as 3 of the
6 applicants who met the attendance criteria, failed the physical elements of the National

Firefighter Skills Test.

The Corporate Leadership Team have recently considered a revised proposal that will
provide a solution to several of GMFRs stations (including Mossley) that demand alternative
crewing solutions which satisfy the risks of the areas and maintain our published response

standards.

Proposed way forward and timeframe for implementation:

A revised duty system based on wholetime staff was approved on the 23" of July 2015. The
revised crewing system will be based on 12 staff working a 24 hour self rostered duty
system. This will provide a 12 hour day shift working from the station and within the
community and 12 hours ‘on-call’ cover within a 4 minute attendance time to the station.
This is the preferred option following the unsuccessful retained recruitment campaign.

A process has commenced to undertake internal and external recruitment for the roles. This
includes approaching other Fire and Rescue Services and to explore opportunities for inter-

brigade transfers. In addition expressions of interest have been sought (22.7.15) for current
‘on-call’ staff at other locations to apply for the wholetime positions at Mossley Fire station.

It is expected that sufficient staff will be identified to undertake the new duty system by
November 2015. This is significantly quicker than if we continue to try and recruit ‘on-call’
firefighters from the community with no assurances as to their ability to pass the required
standards for the role, provide a base location within the 4 minutes or sustain the role long
term due to the heavy commitment in terms of the hours of cover needed.

It remains the position of the Fire Authority that despite the continued financial constraints
that GMFRS faces it will aim to maintain all of its current stations. In working to a model
based on risk, with published response standards there is a recognition that the service can
be provided in several ways. It is also recognised that the traditional ‘on-call’ or retained
model is unsustainable in its current format and a solution based on wholetime staff provides
a more resilient long term solution for Mossley.

If there are any aspects of this report that you feel are unclear or if you have further questions
we would be pleased to either meet with you or provide a further written response.

Once again please allow me to express my deepest condolences to Mr Bailey’s family.
GMFRS are committed to protecting all our communities and providing a response based
on the level of risk associated with the area. We will do this by providing a local and
sustainable solution to how appliances are crewed and will continue to consult to ensure our

communities and partners are fully informed.

Yours sincerely

County Fire Officer and Chief Executive

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