Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0025, written 28 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jan 2016 |
|---|---|
| Reference | 2016-0025 |
| Deceased | Andrew Coates |
| Coroner | David Roberts |
| Coroner area | Cumbria |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RE: Andrew William Telford Coates Deceased THIS REPORT IS BEING SENT TO: 1. Diane Wood, Chief Executive of Cumbria County Council 2. EERE Assistant Director Environment and Community Services CORONER | am David Llewelyn Roberts, Senior Coroner for the coroner area of Cumbria. 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. INVESTIGATION and INQUEST On 5" September 2014 an investigation was commenced into the death of Andrew William Telford Coates aged 41 years. The investigation concluded at the end of the inquest on 22" January 2016. The conclusion of the inquest was:- Cause: 1a) Effects of Explosion and Fire Conclusion: Accidental death CIRCUMSTANCES OF THE DEATH On the 30" August 2014 between the hours of 15.00 and 15.30 at Larch Cottage, | Ecclerigg, Windermere, Cumbria in an outbuilding known as the Fireworks Store located | on the property, an unexplained explosion rendered Andrew William Telford Coates unable to exit the Fireworks Store. Fire consumed the building. This resulted in a fatal level of carbon monoxide inhalation. 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 Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004. | [tis questionable as to whether what amounted to a wooden shed comprised within a | vehicle garage was a suitable structure for a firework store, particularly one licenced for 1000 kg. Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections. In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored. | The effect was to give authority to store explosives of any type up to a net explosive | quantity of 1000 kg. The records of inspections were sketchy. The construction and none firework content of the store at the very least exacerbated the ensuing fire. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. In the light of the evidence from the Inquest, to fully and carefully review the decision making and inspection process of explosive stores in the county. This to include the manner of construction and content of the structures, and the scope of the licences granted. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25'" March 2016. |, 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 copy of my report to the Chief Coroner and to the following Interested Persons:- South Lakeland District Council Vauxhall Motors | 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. i? | 28” January 2016 Signed David L!. Roberts NO (Oke a, REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS RE: Polly Sarah Connor Deceased THIS REPORT IS BEING SENT TO: 1. Diane Wood, Chief Executive of Cumbria County Council 2. BEES Assistant Director Environment and Community Services CORONER ! am David Llewelyn Roberts, Senior Coroner for the coroner area of Cumbria. 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. INVESTIGATION and INQUEST On 5" September 2014 an investigation was commenced into the death of Polly Sarah Connor aged 46 years. The investigation concluded at the end of the inquest on 22” January 2016. The conclusion of the inquest was:- Cause: 1a) Effects of Explosion and Fire Conclusion: Accidental death CIRCUMSTANCES OF THE DEATH ON the 30" August 2014 between the hours of 15.00 and 15.30 at Larch Cottage, Ecclerigg, Windermere, Cumbria in an outbuilding known as the Fireworks Store located on the property, an unexplained explosion rendered Polly Sarah Connor unable to exit the Fireworks Store. Fire consumed the building. This resulted in a fatal level of carbon monoxide inhalation. 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 Fireworks Store at Larch Cottage was, in 2008, licenced under the terms of the Manufacture and Storage of Explosives Regulations 2005. The premises had been subject to a Registration since 2004. It is questionable as to whether what amounted to a wooden shed comprised within a vehicle garage was a suitable structure for a firework store, particularly one licenced for |__| 1000 kg. Evidence was given that the store contained a large amount of other material some of it combustible and access could only be made to the store via an adjoining compartment containing two petrol driven machines. It seemed that this state of affairs had obtained for a number of years, notwithstanding apparently compliant inspections. In addition the licence granted was deficient in that it effectively licenced the entire property instead of designating a specific site. The licence did not specify the type of firework or explosive to be stored. The effect was to give authority to store explosives of any type up to a net explosive quantity of 1000 kg. The records of inspections were sketchy. The construction and none firework content of the store at the very least exacerbated the ensuing fire. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. In the light of the evidence from the Inquest; to fully and carefully review the decision making and inspection process of explosive stores in the county. This to include the manner of construction and content of the structures, and the scope of the licences granted. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25" March 2016. |, 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 copy of my report to the Chief Coroner and to the following Interested Vauxhall Motors | 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 tesponse, about the release or the publication of your response by the Chief Coroner. 28" January 2016 Signed: David LI. Roberts WE Cy 6 4H a,
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.
Cumbria County Council County Council Environment and —_ Services + a Hall > Busher Walk + Kendal + Cumbria * LA9 4DQ Mr D Roberts Her Majesty's Coroner Fairfield Station Road Cockermouth Cumbria CA13 9PT 31 August 2016 Dear Mr Roberts Coroners (Investigations) Regulations 2013 Regulation 28 Report to Prevent Future Deaths Regarding the Late Polly Connor and Andrew Coates | write with reference to your Regulation 28 letter dated 27” January 2016, in respect of the storage of fireworks at Larch Cottage, Ecclerigg, Windermere. Please accept this letter and Cumbria County Council's letter of the 24" March 2016 as the Council's complete response to you Regulation 28 letter. Within your letter you raised concerns and recommended that the Council should “fully and carefully review the decision making and inspection process of explosive stores in the county. This is to include the manner of construction and content of the structures and the scope of licences”. Our letter dated the 24” of March 2016, detailed the actions taken to that date, however due to the flooding in Cumbria in December 2015 we had been unable to arrange for the external audit of our processes and licensed stores. It was agreed that Cumbria County Council would take the following action by the 31% August 2016: e Ensure that all officers who are conducting firework licencing inspections will receive training on the requirements of the Explosives Regulations 2014, and will specifically examine storage requirements. e Conduct an external review of Quality Assurance procedures. e Externally validate the large firework stores in Cumbria, so that expert opinion on the construction, suitability and compliance with the regulations could be sought. « Review of existing licences by external expert. In our letter dated 24" March 2016, we advised you that the HSE were to conduct the external audit of our processes and licensed stores. —_—€§, subsequently unable to conduct the audit. Therefore Cumbria County Council, contracted an independ , to validate the firework stores licensing and review the Council's licenses and procedures. is the Lead Officer for Explosives Serving the people of Cumbria apprenticeships 40" cumbria.gov.uk "[W) Good for our Business Stas? for the Chartered Trading Standards Institute, and is a Fellow of the Association for Petroleum and Explosive Administration with over 25 years experience. ! can confirm that the following actions have being undertaken to address your concerns: e Training - on 17 June 2016, ae. provided training to all operational Trading Standards Officers and fireworks administrators in respect of The Explosives Regulations 2014. This training specifically covered the storage of fireworks and construction of firework stores, separation distances, hazard types of fireworks and licensing requirements. * Quality Assurance Procedures and Review of Existing Licenses - EM reviewed the fireworks quality assurance procedures and work instructions implemented by Cumbria Trading Standards. He identified some minor amendments to the procedures in his report, which have now been incorporated into the Council's procedures and practices. e Firework Store review -E also conducted an audit of the large Cumbrian fireworks stores and their associated licenses. In respect of the mandatory legal requirements he identified one issue over the quantity and then the subsequent separation distances specified in one licence. This has now been rectified. There were also some issues identified with the best practice requirements which the businesses determine how they comply with these requirements. Compliance of these issues has been agreed with the businesses concerned. | am pleased to advise you that Cumbria County Council has addressed the issues which were identified in 5 report, and the licensing procedures and Firework Stores in Cumbria were complainant with the Explosive Regulations 2014. The Council has also provided additional training for all staff involved in firework licensing. | hope that the independent report and our interim response dated 24" March 2016 provides you with reassurance that Cumbria County Council is now fully meeting its statutory responsibilities under the Explosive Regulations 2014, as the enforcing and licensing authority. Should you wish to discuss the content of the letter or attached report further, please do not hesitate to contact me. Yours sincerely, Assistant Director — Economy & Environment
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