Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0383, written 22 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Sep 2015 |
|---|---|
| Reference | 2015-0383 |
| Deceased | Emma Waring |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Department for Communities and Local Government
2.
3.
1
CORONER
I am Simon Nelson, Senior Coroner for the Coroner area of Manchester North
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28
and 29 of the Coroners (Investigations) Regulations 2013
3
INVESTIGATION and INQUEST
On the 12th of March 2015 I commenced an investigation into the death of Emma Waring for whom the
cause of death was given as being that of 1a inhalation of the products of combustion. At the
inquest on 17 September 2015 the conclusion was one of an ‘accidental death’.
4
CIRCUMSTANCES OF DEATH
Emma Waring was 23 years old at the time of her death. She was working with a family support
worker as a result of her 2 year-old son having been taken into care 8 months previously. She was
known to be a heavy drinker and cigarette smoker and was by all accounts a vulnerable individual..
She moved into her rented accommodation in July 2014 and as with similar dwellings in the
immediate vacinity it had been fitted with ‘hard wired’ smoke alarms by Rochdale Boroughwide
Housing. The evidence at inquest indicated that the fire had started at some time after 01:50 hours
on 7 March 2015; the smoke alarm activated and would have been audible to neighbours. However
the initial call to the emergency services was not made until 02.40 hours. It was more likely than
not that a cigarette had come into contact with bedding materials and that whilst the deceased was
asleep the fire had developed filling the bedroom with toxic smoke. At some point the deceased
had became aware of the fire, possibly due to the smoke detectors operating, and had attempted
to escape but had been quickly overcome by the toxic products of combustion
designated Community Safety Manager with the Greater Manchester Fire and
Rescue Service confirmed in evidence that the Service ‘strongly advocated the installation of
domestic automatic water suppression systems (sprinkler systems) and that had such a system
been installed in the deceased’s home then the chances of her surviving this fire would have been
significantly increased
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:-
Immediate and positive consideration of the compulsory inclusion in the design, planning and
building phases for residential properties (especially for those properties housing vulnerable
individuals) of Automatic Water Suppression Systems more commonly known as ‘domestic
sprinklers’ so as to provide further safeguards in the event of accidental or indeed deliberate fires
in such premises.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe each of you respectively
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 21st October
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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
1. Family of the deceased
2. Greater Manchester Fire and Rescue Service
3. Rochdale Boroughwide Housing
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 from. 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
Date: 22nd September 2015 Signed: Simon Nelson
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.
c I Sandbrook House Sandbrook Way Rochdale OL11 1RY Telephone: Website: www.rbh.org.uk FAQ: HM CORONER MR. S. NELSON - Direct Line: HM CORONER’S OFFICE E-mail address: PHOENIX CENTRE CHURCH STREET ROCHDALE Our Ref: OL1O 1LR Date: 22ndJune 2016 Private and Confidential Dear Sir Re: RBH RESPONSE IN REGARD TO REGULATION28OF THE INQUESTINTO THE DEATH OF MISS EMMA WARING, I am writing as Chief Executive on behalf of Rochdale Boroughwide Housing (RBH) in regard to the above Coroner’s Inquest and the subsequent notification to the Department of Communities and Local Government made under Paragraph 7, Schedule 5 of the Coroner’s Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013 and dated 2n2d September 2015. We received a copy of the above report as an ‘Interested Party’ and although we were not required to respond directly regarding the Regulation, given the unfortunate circumstances of this tragic loss of life I felt it appropriate to offer some background information in relation the fire safety activities RBH undertakes both as a sole entity and also in partnership with other relevant agencies. With specific regard to the installation of domestic sprinklers detailed in your recommendation, I am aware that the Chief Fire Officers Association (CFOA) has on a number of occasions lobbied for such legislation and following a successful campaign led by Vale of Ciwyd AM to make domestic sprinklers compulsory in new and converted homes (including houses and flats) across Wales from January 2016 onwards issued a position statement as recently as March 2013 to request that this be extended to cover the whole of the UK. At this present time, it is my understanding that the plans for UK wide legislation have not been taken forward. However, despite the lack of such legislation RBH has delivered domestic sprinklers in several properties occupied by some of our most vulnerable tenants. The decision to install domestic sprinklers was based on a number offactors not least ofwhich was a desire to maintain their quality of life whilst at the same time offering them the very best protection from fire that we could. These installations were approved by Greater Manchester Fire and Rescue Service who were involved in the process from the outset and were installed by fully qualified sprinkler engineers. The sprinklers are connected to integrated smoke alarms which will only operate when a fire actually occurs and actuates a sprinkler head thereby significantly reducing the likelihood of false alarms. The system itself only requires an annual maintenance visit when the pressure and flow are tested meaning that from an occupier’s perspective the system is effectively maintenance free. T “TOUCH Fol!ow rbhousin DO Visit us at rbh.org.uk or talk to us on 0800 027 7769 or (01706) 274100 Rorhdale Boroughwicie HousingLrnted is a cbaritahlcommunitybenefit uo.oety FCA re rer number3152 R. Registeied Office Sandbmook House, SandbmookWay, RochdaleOL11 1RY Reistercdasa provider oFsocial housing HC rsisLsrnumber 4FM7 In addition, all RBH properties are fitted with hard-wired smoke detection in line with current legislation. Although a number of our properties fall under the auspices ofthe FS(RRO)2005, the property in which Miss Waring was resident (and the vast majority of those we manage) was not covered by any enforceable fire safety legislation. We none the less take the issue of fire safety extremely seriously and, as such entered into a formal Service Level Agreement with Greater Manchester Fire and Rescue Service in August 2013 for thejoint provision of Safe & Well visits to all our tenants. These visits are offered regardless of circumstance however, due to resource implications for both organisations they are presently targeted toward those considered to be most ‘at risk’ from fire due to their vulnerability in whatever regard that is evidenced. The visits are by self, RBH or partner agency referral and are undertaken by specific appointment chosen by the recipient themselves subsequent to which we jointly act upon any recommendations that are forthcoming including the potential onward referral to a number of partner agencies should additional support be identified. All visits and any actions taken by the agencies concerned are recorded by our Fire Safety Consultant who acts as our Single Point of Contact for this initiative and any personal information is shared in line with a formal Information Sharing Agreement with Greater Manchester Fire and Rescue Service signed by both parties in December 2013 via a secure electronic system. We are also currently working with Rochdale Council’s Strategic Housing Service on a project designed to offer additional support to those identified as hoarders, an issue which has become more prevalent over recent years. The intention of the project is not only to ensure a consistent approach across all housing providers here in Rochdale but also to ensure that all RBH staff have the necessary support to deal with such issues as and when they are identified. The ‘toolkit’ is based on the internationally recognised ‘Clutter Image Rating Scale’ which is also used by several other partner agencies not only here in Rochdale but across Greater Manchester as a whole. Regardless of all of the above, we will continue to seek new and innovative ways of delivering both our statutory fire safety duties and those which whilst not mandatory, we consider to be integral to our desire to be a housing provider of choice and to offer our tenants the best possible protection from fire. Although on occasion and despite our very best efforts tragic incidents such as that involving Miss Waring have the potential to occur, we are absolutely committed to continuous improvement and determined that any relevant lessons be learnt in our earnest attempts to ensure we do the very best that we can for all our tenants. I sincerely hope that the above information will prove useful to the outcome ofyour inquest and assure you ofour very best attention at all times. Yours faithfully ) r’— IF-——’ -=;--_J Gareth Swarbrick Chief Executive
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