Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0092, written 4 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2016 |
|---|---|
| Reference | 2016-0092 |
| Deceased | Lee Gaunt |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The County Fire Officer and Chief Executive, Greater Manchester Fire and Rescue Service, 146, Bolton road, Swinton, Manchester M27 8 US 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 21" October 2015 | commenced an investigation into the death of Lee Richard Gaunt dob 26" October 1973. The investigation concluded on the 11” February 2016 and the conclusion was one of Suicide. The medical cause of death was 1a Hanging. 4 | CIRCUMSTANCES OF THE DEATH On the 17 October 2015 he went to work the night shift at Stalybridge Fire Station. He had recently been suffering a loss of confidence at work following the death of a colleague in a fire in Manchester where he was one of the commanders. He was found hanging from a tree at the Fire Station. 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. — 1. There appeared to be rather less than effective support from Occupational Health and it took a long time for the deceased to be able to see the doctor. 2. Whilst it was known by the Fire and Rescue Service that he was suffering as a result of the death of his colleague, nonetheless he was required to take on the extra duties of Crew manager and Watch Manager. 3. In the aftermath of the death of his colleague, and whilst being forced to take on the extra Watch Manager job, he was also having to cope with the extra (and as he regarded it, strenuous) task of leading the fire-fighters as First-Responders to assist North West Ambulance Service in attending cardiac arrest calls. 4. It became apparent in the course of the evidence, that the deceased and his wife felt there was a general failure by the GMFRS to care for and support staff in stressful situations. 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. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29" April 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 namely EE wife 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. jay send a copy of this report to any person who he believes may find it useful or ofjntefest. You may make representations to me, the coroner, at the time of your resgons¢, about the release or the publication of your response by the Chief Coroner. 4.3. John Pollard, HM Senior Coroner
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.
Your Reference JSP/ER/02498-2015
Our Reference POR/MH
Contact 0161 608 4001
Mr John Pollard
H M Coroner
HM Coroner's Court
Mount Tabor County Fire once Cid Execie
Mottram Street y
Stockport SK1 3PA creater Ma srveand
ae chester Rescue
146 Bolton Road
Swinton
Manchester M27 8US
i Telephone 0161 736 5866
Date 25 April 2016 Teens
www. manchesterfire.gov.uk
Dear Mr Pollard
Inquest into the death of Lee Richard Gaunt — Response to Regulation 28 Report
Further to your report to prevent future deaths issued on 4 March 2016, | respond to the
concerns set out within the report as follows:
Concern 1
1. GMFRS’s occupational health providers in 2013 were different to the current providers.
GMERS retendered its occupational health service provision on the expiry of the
previous contract on 31 January 2015. The current providers are Healthwork and you
heard from one of their directors, HE at the inquest.
The current provision operates by way of triage with an escalation procedure. If an
immediate doctor appointment is considered necessary the appropriate referral will be
made. If a follow up appointment is required after a nurse appointment, this will
automatically be with a doctor.
We have for completeness fed back the outcome of the inquest and your concerns to
them.
Concerns 2 & 3
2. GMFRS was aware that the deceased had been suffering ill health as a result of the
death of a colleague in July 2013. The medical advice that GMFRS received in
January 2014 was that the deceased was fit for his duties in his substantive role of
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Crew Manager. GMFRS was not aware that the deceased had begun to suffer ill
health again when he took on additional duties on the retirement of his Watch
Manager on 30 August 2015 and the implementation of the collective agreement to
respond to cardiac arrests on 15 September 2015.
GMFRS operates a mandatory system of critical incident debriefing following
attendance at traumatic incidents. Since November 2015 GMFRS has been piloting a
system known as Trauma Risk Management (TRiM) which is a proactive, peer
delivered initiative for supporting individuals following exposure to traumatic events.
The TRiM protocol is widely used in the Armed Forces and Police services and is fully
compliant with the National Institute of Health & Clinical Excellence (NICE) guidelines
for the delivery of post trauma support.
GMERS is in the process of evaluating the pilot scheme so as to assess whether it is
appropriate for the organisation. If itis, it is the intention is to inform the whole
organisation of TRIM and to establish a network of practitioners at all levels across all
directorates.
Concern 4
3. GMFRS has amended its procedures to allow employees to seif-refer for counselling
via its occupational health provider.
In addition to the matters referred to under Concerns 2 & 3, GMFRS established a working
group with trade union participation examining the facilities available for addressing the
effects of dealing with stressful situations. This working group will continue and seek on-
going involvement and contribution from all relevant trade unions and will inform GMFRS's
strategy and new organisational structure in this regard, which is currently under review.
GMERS has taken due notice of the concerns you have raised and | hope that you find our
responses apposite.
Yours sincerely
ve
COUNTY FIRE OFFICER &
CHIEF EXECUTIVE
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