Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0482, written 24 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Feb 2015 |
|---|---|
| Reference | 2015-0482 |
| Deceased | Christopher Butler |
| Coroner | Peter Clark |
| Coroner area | Oxfordshire |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Mr David Etheridge OBE, Chief Fire Officer, Fire and Rescue Service
Headquarters, Sterling Road, Kidlington, Oxfordshire, OX5 2DU.
1 | CORONER
| am Peter G Clark, Assistant Coroner, for the coroner area of Oxfordshire
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 17 September 2014, an investigation into the death of Christopher John Butler, aged
55, was commenced. The investigation concluded at the end of the inquest on 21
January 2015. The conclusion of the inquest was a narrative verdict.
The deceased died from a combination of smoke inhalation and alcohol intoxication
following a fire at his home. The cause of the fire was an overheated electrical cable
serving the cooker and single 13amp plug socket. The medical opinion on the cause of
death was:
1a) Smoke inhalation and alcohol intoxication
Other significant conditions contributing to the death but not related to the death or
conditions causing it was:
ii) Asthma
4 | CIRCUMSTANCES OF THE DEATH
The deceased had a previous medical history of alcohol intake above recommended
sensible limits, suspected epilepsy and asthma.
On Friday 5 September 2014, Oxfordshire Fire and Rescue Service were called toa
house at his home address, being I The fire was believed to
have started between 11am and 12pm on that day. The body of the deceased was
removed from the premises and death was confirmed by Paramedics at the scene. The
degree of intoxication of the deceased at the time would have impaired his ability to
recognise the danger of smoke and his ability to escape the fire.
Fire investigation was undertaken and formal evidence provided indicates the cause of
: fire appears to be due to an electrical malfunction in relation te the electrical cabling
Se ome ie pe examination of the inner core of the cable indicated that
| the cabling through a wooden joist caused the additional insulation of the cable and
possible damage due to the acute bend in the wire. This defect in the insulation of the
cabling could have been present from the date of construction over 25 years ago
The property had an old style fuse box and evidence was received that a more modern
trip fuse would have more likely prevented the cable overheating to the extent where a
fire occurred.
| During the course of the inquest the evidence revealed matters giving rise to concern. In
| The MATTERS OF CONCERN are as follows. —
CORONER’S CONCERNS
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 fault in the wiring that resulted in this fire may be present in other similar properties
within the estate built at the same time. Electric testing will not necessarily reveal this
fault’ Consideration as to what information and action can be undertaken by the Fire
and Rescue Service to alert the local community on this matter.
This issue is brought to your attention for solution.
ACTION SHOULD SE 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 21 April 2015. |, the coroner, may extend the period but a formal application
for this will need to be made in time.
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. |
| response, about the release or the publication of your response by the Chief Coroner.
COPIES and PUBLICATION
{ have sent a copy of my report to the Chief Coroner and to the following Interested
Persons who may find it useful or of interest.
The family of Christopher John Butler.
lam 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
of of interest. You may make representations to me, the coroner, at the time of your
24 February 2045 4, .
fy Peter oe Crark
Assistant Coroner
to
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.
OXFORDSHIRE COUNTY COUNCIL Date: 16 April 2015 Oxfordshire County Council Our ref: Fire and Rescue Service Your ref: 01638-2014 Headquarters Sterling Road Kidlington Oxfordshire OX5 2DU Mr Peter G Clark Assistant Coroner David Etheridge Oxfordshire Coroner's Office Chief Fire Officer The Oxford Register Office 2" Floor OXFORDSHIRE | 1 Tidmarsh Lane CORONERS OFFICE | Oxford a OX1 1NS 17 APR 2015 ) 7 Dear Mr Clark PRECEIVED --nnesnnn siaacs ba ! Re: Regulation 28 - Further to Fatal House Fire on 5 Sept. 2014 involving Christopher John Butler of EEE and Inquest at Oxford Coroners Court on 21 January 2014 Thank you for your letter of 24 February 2015, written under Regulation 28 of The Coroners (investigations) Regulations 2013, concerning the inquest into the death of Mr Christopher John Butler who died tragically in the fire at = on the 5 September 2014. Through your good offices, may | take this opportunity to express my sincere condolences to the family of Mr Butler. Following the receipt of your letter Oxfordshire County Council Fire and Rescue Service (OCCFRS) has undertaken a comprehensive review of the circumstances relating to this case. We have taken this opportunity to further challenge how we identify, manage and deal with risk in the community. We are also reviewing how to further improve our processes concerning investigating and fully understanding the circumstances to a future tragic incident. We consider that this approach will enable further information to suppori all investigations into the cause of the fire and also the wider causation that lead to these fatal events. | have considered the recommendation within your letter and offer the following response: | can confirm that the circumstances relating to this case are under review; the review and our suggested future approach is using the Health and Safety HSG65 model of Plan, Do, Check and Act to ensure that the organisation improves its ability to identify and manage risk within the local community. | have asked my Home and Community Safety Team to review the partnership arrangements in place across all stakeholders that came into contact with Mr Butler and identify if any concerms around risk were known and flagged to relevant stakeholders. This will ensure future “Ss, INVESTORS IN PEOPLE intelligence concerning ‘at risk’ groups or individuals is shared earlier and in a more structured fashion. We are also making improvements and reviewing our approach to incidents of this type to ensure that a critical review of our risk management is carried out earlier in order to inform any internal or external agency investigation or Coroner's Hearing. This new approach will be initiated for all significant “persons reported” (where a life is considered to be in the property) incidents so we can learn from a wider number of incidents which had the potential to lead to a fire fatality. This will enable us to identify the risk factors beyond those that we currently scrutinise and share this with the wider fire sector regionally and nationally. The outcome of the fire investigation in this specific case identified that the direct cause of the fire was attributed to an overheated cable caused by a sharp ninety degree bend in the wire probably formed during the installation stage. This could be replicated and present in many other internal wiring situations both locally and nationally. We will shortly be publishing and providing a case study concerning this specific incident to the National Inspection Council for Electrical Installation Contracting (NICEIC) and the Electrical Safety Council to enable them to use it in the education of electricians around the country. | have also asked our OCCFRS Home and Community Safety Team to inform and educate residents in the local area and as a result the following activities are being undertaken: e We have identified a number of properties that were broadly similar in age and design and we wrote to these residents highlighting this fatal incident and have provided them with some additional preventative information e We are reviewing the property information to determine who the house builder was and whether there have been any local or national trends of fires with this organisation and will take further action as appropriate to our findings e We have utilised our close links with Oxfordshire County Council's Social and Community Services in order to identify any specific vulnerable residents within this targeted area in order to provide further personal assistance to them e We are also working with Adults and Social Services to review our Near Miss and Fatal Incident Review process in order to ensure our future approach is comprehensive and will deliver internal reflective learning and offer best practice within the organisation and to the wider fire sector e We are also working with Electrical Safety First in order to provide these residents with a comprehensive home electrical safety booklet plus we are signposting them to recognised electricians via the OCC Trading Standards ‘Trust a Trader’ list if they needed some further expert advice e We have identified a number of other local information avenues, for example Parish newsletters and residents groups to communicate fire safety advice and specifically some electrical fire safety advice e We have released a general electrical fire safety press release and updated our public websites to raise the awareness and target home electrical testing including the safety benefits and importance of modern fuse box designs. As fire and rescue services, we continually learn from each other following tragic and unusual incidents such as this and we will share the circumstances of the cause of this fire and the subsequent actions with 51 fire and rescue services via the Chief Fire Officers Association. 1 attach a copy of the letter that we have sent to the residents in Kidlington and a copy of the Electrical Safety First booklet. | am grateful for your recommendations and can assure you of Oxfordshire County Council Fire and Rescue Service’s continued commitment to ensuring that the safety of the community within Oxfordshire is our top priority. | do hope the actions and measures we have taken above provide reassurance and directly address the issues raised in your Regulation 28 letter. Should you wish for any clarification concerning our course of action, please do not hesitate to contact me at the above address. Yours sincerely AG fidge OBE Chief Fire Officer Direct line: Email: www.oxfordshire.gov.uk/fire ¢ “S, INVESTORS IN PEOPLE
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