Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0130, written 30 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Apr 2016 |
|---|---|
| Reference | 2016-0130 |
| Deceased | William Thompson |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Community health care and emergency services 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: Prevention of Future Deaths report
William THOMPSON (died 07.11.14)
THIS REPORT IS BEING SENT TO:
1. Mr Tim Shields
Chief Executive
London Borough of Hackney
Hackney Town Hall
Mare Street
London E8 1EA
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 10 November 2014, I commenced an investigation into the death of
William Thompson, aged 72 years. The investigation concluded at the
end of the inquest earlier today. I made a determination of accidental
death.
4
CIRCUMSTANCES OF THE DEATH
Mr Thompson died in a fire at his home caused by a discarded cigarette.
His bedding caught light and he was killed by smoke inhalation. Mr
Thompson lived in supported housing.
1
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 evidence I heard at inquest was that, whilst smoke and heat
detectors were installed in Mr Thompson’s hall and kitchen, there was no
smoke detection system in his bedroom.
He was known to be at significantly raised fire risk because of his
smoking, drinking and immobility (he used a Zimmer frame). London Fire
Brigade had been called to his home more than once in the past.
However, his social workers never addressed their minds to the question
of whether there was a smoke detector in his bedroom and, if not,
whether that might be useful.
This seems to be an area that would benefit from exploration for
particularly high risk service users.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 3 July 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Group Manager, London Fire Brigade
daughter
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 form. He may send a copy of this report to any person who
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
30.04.15
3
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.
@Hackney Health and Community Services Hackney Council 2 Hillman Street London E8 1FB Coroner M.E. Hassell 020 8356 7290 Senior Coroner (nner North London St. Pancras Coroner's Court Camley Street 31 March 2016 London N1C 4PP Dear Coroner Hassell, Re: Prevention of Future Death Report: Mr William Thompson (died 07. 11. 2014) |. am writing on behalf of Tim Shields, Chief Executive, in response to the Prevention of Future Deaths Report, dated 30 April 2015, received by us on 11 February 2016. Measures taken by the Council to seek to prevent future deaths in this manner include the City & Hackney Safeguarding Adults Board commissioning a Safeguarding Adults Review, under the provisions of the Care Act 2014, which has twenty six recommendations for improving practice and procedures across all of the partners and agencies involved with this case. Other measures have also been implemented, some in relation specifically to practice in the Council and others with partners to prevent as far as is possible further deaths in similar situations to that of Mr Thompson. These are highlighted in the Report and Action Plan attached with this letter as Appendices 1 and 2. | trust that the attached Report and Action Plan provides you with sufficient information to assure you that the measures we have taken are satisfactory and appropriate and sufficiently robust to prevent as far as is possible further death in similar situations. Should you require further information please do not hesitate to contact me. Yours sincerely x Laur borg Lot - Corporate Director, Health and Community Services () INVESTORS IN. PEOPLE UK
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.