Stephen Hunt

Date of report	8 Jun 2016
Reference	2016-0216
Deceased	Stephen Hunt
Coroner	Nigel Meadows
Coroner area	Manchester City
Category	Community health care and emergency services related deaths · Other related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

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.

Stephen Alan HUNT (Deceased)

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS .

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

e@ The Rt Hon. Theresa May MP, the Home Secretary
© Mr Peter Holland CBE, Chief Fire and Rescue Adviser

Copied for interest to:

e The Chief Fire Officer of Greater Manchester Fire and Rescue Service
e The Chief Fire Officer of Merseyside Fire and Rescue Service
e The Chief Fire Officer of West Yorkshire Fire and Rescue Service
e The family of the Deceased
e The President of the IFE
e The other Interested Persons in the Inquest
CORONER
1am Nigel Meadows, H.M. Senior Coroner for the area of Manchester City.

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.

INQUEST

In summary terms the jury found that the deceased had been untawtully killed (by
unlawful act manslaughter by arson) by a joint enterprise involving two juveniles and
answered a number of other specific factual issues.

Narrative conclusion comprising the answers to the following questions:

Question 1: Are you satisfied so that you are sure that the deceased was unlawfully
killed by the acts of a single person?

Answer: No

Question 2: Are you satisfied so that you are sure that the deceased was unlawfully
killed by the acts of a joint enterprise?

Answer: Yes

Question 3: Do you find that the fire was probably deliberately started by the acts of one
person?

Answer: No

Question 4: Do you find that the fire was probably deliberately started by the acts of a
joint enterprise?

Answer: Yes

Question 5: Was the caged cardboard storage area and the racking up the stairs from
the emergency exit doors probably installed in or about the summer of 2009?

Answer: Yes

Question 6: Was the caged cardboard storage area and the racking up the stairs from
the emergency exit doors probably installed and in place on 2 August 2012 when a fire
tisk assessment was Carried out and was it in place on 13 July 2013?

Answer: Yes

Question 7: Did the presence of the caged cardboard storage area and the racking up
the stairs from the emergency exit doors contribute to the fire developing?

Answer: Yes

Question 8: This question asks you about the probable control measures that were in
place during the afternoon shift on 13 July 2013:-

(a): Was the period of wear for BA crews entering through the doorway in sector 1
probably limited to a period of time during the day shift?

Answer: Yes
(b) If the answer to the previous question is "yes", what was the time limit?
Answer: Maximum 20 minutes

(c) Were most BA crews entering through the doorway in sector 1 probably told to
remain at the top of the stairs just inside the doorway and fight the fire from there only?

Answer: Yes

(d) Were there any other probable safety contro! measures instigated in sector 1
doorway for BA crews entering the building during the afternoon of 13 July 2013?"

Answer: Yes, there was a second safety officer to keep an eye on BA crews entering the
doorway and to keep visual and/or verbal contact to check that they are okay.

Question 9: Were the safety control measures that you have identified in response to
question 8 probably communicated to:-

(a) The entry control officer who sent the deceased and P| into the building?
Answer: No

(b) The new sector commander for sector 1 at the changeover of shifts at about 2000
hours on 13 July 2013?

Answer: Yes

Answer: No
Question 10: Were the same safety measures that you have identified in response to

question 8 probably in place when the Deceased and his colleague entered the building
and if not should they have been?

Answer: Measures were in place although not implemented. These measures should
have been carried through over handovers.

Question 11: Did the new sector commander and/or entry control officer for sector 1
probably fail to understand or comprehend and then implement the safety measures
they were advised about?

Answer: The new sector commander misinterpreted the brief and the entry control officer
was not fully informed and, therefore, couldn't implement the safety measures.

Question 12: On or about the time the deceased and his colleague entered the building
was either of the new Entry Control Officer, the Sector Commander, the Sector Safety
Officer, probably aware of the following:-

(a) that the previous BA teams had been limited to a 20 minute wear? If so, please
specify who (by reference to their role and not their name - for example, Sector
Commander; Entry Control! Officer; Sector Safety Officer etc) knew what?

Answer: Ops commander, Sector 1 commander, Second safety officer, Ops support,
Ops assurance and Sector safety officer

(b) that they had been directed to go to the top of the stairs and fight the fire at that point
but go no further? If so, please specify who (by reference to their role and not their name
- for example, Sector Commander; Entry Control Officer; Sector Safety Officer; etc)
knew what?

Answer: Sector 1 commander, BA entry control officer, second safety officer, incident
commander, operations commander, operational support, operations assurance, sector
safety officer, logistics officer, and sector 4 commander.

(c) that a safety officer had been dedicated to watch over them and keep in
communication? If so, please specify who (by reference to their role and not their name
- for example, Sector Commander; Entry Control Officer; Sector Safety Officer; etc)
knew what?

Answer: Second safety officer, sector 1 commander, operations commander, operational
support, sector safety officer, and sector 4 commander.

Question 13 (a) What brief was probably given to the deceased and his colleague before
entering the building at 20:04 hours; and (b} had this brief changed from earlier briefs
and, if so, in what respect/s?

Answer: The deceased and his colleague were two briefs. The entry contro! officer
gave:" Go to the top of the stairs, take over, sit there and squirt water, top of the
mezzanine, you know what the crack is". The second safety officer gave this quote "Go
to the top of the stairs, turn left, turn right, use the thermal imaging camera, and spray
water from there." The brief changed from earlier briefs due to the wording -- sorry, the
brief changed from earlier briefs due to the wording with the inclusion of the word
"mezzanine" and no direct instructions.

Question 14: Did the deceased and his colleague probably follow their brief?

Answer: Yes, they followed their brief as they understood it. The confusion was due to
the use of the term "mezzanine" and "seek out hot spots” may have led them to
misunderstanding the brief.

Question 15: What factors probably contributed significantly to the death? They need not
be the sole or even the principal cause of death, but they must be more than merel

minimal.

Answer:

1. Lack of communication / information at handover

2. Lack of communication, information at briefing and debriefing
3. Misinterpretation of instructions

4. incorrect decision making

5. Competency within roles given

6. Paul's Hair World storeroom layout, internal conditions (stock, debris, smoke
detectors)

7. Breakdown of telemetry radio communications

8. Inadequate fire risk assessments

9. Inadequate fire safety measures within Paul's Hair World (Fire drills)

10. Act of vandalism / criminal damage.

CIRCUMSTANCES OF THE DEATH

The events concern a business known as Paul's Hair and Beauty World (“PHW”)
operating from the ground floor of 21 to 33 Oldham Street in the city centre of
Manchester. The business is run by EEE and he took up occupation of this
premises in approximately 2003 as a sub-tenant. He then became the main tenant in
2006. Over the years his business has been quite successful and he has other outlets.
The nature of the business is the sale in particular of human and synthetic hair
extensions as well as associated hair and beauty products. He also had an on-line
business.

Prior to PHW's occupation, the premises was used as a nightclub requiring a public
entertainment licence. It has a main front entrance as well as a rear emergency exit
comprising of two doors which open outwards, but also another emergency exit which
led onto a protected staircase also towards the rear of the premises. It seems that the
protected staircase emergency exit was not used and indeed was padiocked when PHW
took over the premises. The evidence indicated that it had never been used. The
business kept a substantial amount of stock usually in large boxes. The front of the
premises was designed as a shop in which customers could simply walk through aisles
of products and it also had display cabinets. There was a main counter system. The rear
of the premises which used for storage and office space and this was at a premium. It
seems that over the years in order to boost the level of stock that could be kept a system
of wooden racking from floor to near ceiling had been fitted out. It seems that by 13 July
2013 the disused emergency exit doors had been covered with racking for some years.

In or about 2004 who had previously been a Greater Manchester Fire and
Rescue Service (“GMFRS”) firefighter for 23 years, started an unincorporated business
known as Firefighter UK. Originally, he simply serviced fire extinguishers at PHW but ,as
his business developed , he subsequently held himself out as being a competent fire risk
assessor. In 2009, he completed a formal fire risk assessment document for PHW. He
returned in 2010 and 2011 to service the business's fire extinguishers. However, in July
2012 PHW had a health and safety assessment carried out by| of a business
known as Spectra Business Solutions and it was noted that the businesses fire risk
assessment was out of date. Mr Aspinall was contacted and arranged to attend again,
and conducted what he told the court was a fresh or initial fire risk assessment.

In about the summer of 2009, yO of RA Smith Joinery was asked by PHW to
construct a mezzanine floor level within the storage area at the rear of the demised
premises and in addition to create some additional racking to store products which run
up from the emergency exit doors at the rear of the premises on the right-hand side as
you look at them from the outside. He also created a caged cardboard storage area
which was situated behind the left hand door as you look at them from the outside.

Consequently, when IEEE carried out his first fire risk assessment in 2009, the
evidence suggested that the mezzanine together with the additional racking by the
emergency exit doors and the cardboard storage area had been created and was in
existence and in use. That would be the same position in 2010 and 2011 and indeed
again in 2012.

The emergency services were called at 14:59 hours and initially three fire appliances (or
pumps) attended with other supporting colleagues travelling by other vehicles. However,
very quickly it became clear that additional resources would be required to fight the fire
and eventually some twelve pumps attended, in addition to initially one and then a
second aerial platform. The fire was deep-seated and extremely difficult to tackle.

On 13 July 201 and HB hac travelled by train into Manchester from
Bolton in order to visit the city centre. [EEN had her 15th birthday only a few days
before and she had been given some money by her father. The weather on that day was
particularly warm with temperatures reaching 27°C. Both girls were intending to visit a
business known as Affleck's Palace which is adjacent to PHW's premises.

One entrance into Affleck's Palace is situated near to the rear of PHW's premises on

what is known as Tib Street. Significant parts but not all of the events of relevance that

happened thereafter were captured on CCTV cameras. The evidence indicates that
and went to sit outside the rear emergency exit doors of PHW at

about 14:38:32 hours. Both girls wanted to smoke and it seems that they sat down and

lit and smoked a cigarette each. IEE had a hand bag which contained both the

cigarettes and lighters which were in their possession. There was a significant dispute

as to fact between EEE and = about what transpired. It was contended

b that for some time she had difficulty in practical terms in actually using a

lighter and she got her friends to do so and in particular

told the court that she was still unable to light a cigarette using a lighter on
13 July 2013. She said that lit her cigarette for her on this occasion and
passed her the lit cigarette. However maintained that whilst]bad
been unable to light her own cigarettes using a lighter for some time, she was able to do
so by 13 July 2013 and did in fact light her own cigarette on this occasion. It would be
fair to say that there were inconsistencies and contradictions in both their accounts but
this was a matter of fact for the jury to determine.

The girls sat down and smoked the cigarettes slowly and chatted for a few minutes. The
CCTV shows their leaving the vicinity of the rear emergency exit doors 14:45:36 hours.
However, it is suggested that on close observation of the CCTV images the first signs of
smoke from the fire are seen at about 14:46:33 hours. This was before the girls leave
the doorway. At about 14:47:06 smoke was clearly visible. In other words about one and
a half minutes after the girls moved away from the coors. EEE the shop manager,
ran around the back and is seen on camera at 14:47:11 hours and she thought that it
had taken about 2 minutes being alerted to the fire to arriving at the back doors. The fire
itself was discovered by an employee of the business known as i. Allowing a
margin of error for back calculation it was estimated that he had actually discovered the
fire at about 14:45:35 hours. This means that the fire was first noticed when|
andi would still have been at the doors. When it was first discovered the fire
was described as being in the cage cardboard storage area with flames about 4 or 5 feet
high. As a matter of common sense it would have taken some time to get to that stage
after ignition, albeit quite rapidly as the expert evidence indicated.

The court heard from a total of four expert witnesses in relation to the cause of the fire.
Merseyside Fire and Rescue Service have been appointed to investigate the fire and the
fire investigator involved was He was an extremely experienced fire
officer with over 10 years experience as a fire investigator and had investigated in
excess of 1000 fires. He visited the scene of the fire following the fatality and took a
number of photographs. Subsequently a number of tests were conducted in a simulation
of the location. In his opinion, the fire had been caused by naked flame passed

underneath the left-hand door as you look at them from the outside coming into contact
with cardboard in the store.

In simple terms on the accounts given by both juveniles, neither of them could have
been responsible for starting the fire. There was no evidence of any other third party
involved. Even if there had been a discarded cigarette involved originating from either
them they both told the court that they smoke their cigarettes virtually down to the filter
and had stubbed their cigarettes out very shortly before leaving. Irrespective of the
consideration of there being = = in the sense of tobacco to burn in the
cigarette, the experiment that conducted would suggest that even in
unique circumstances it would have taken another three and a half minutes for the fire to
have started and it was quite clear that the fire had started when the girls were at the
back door.

P| opinions were supported vy who is a forensic scientist and
has been investigating fires since about 2002. He had been involved in advising the
police and the CPS in connection with the original prosecution of [EEE He
agreed that the seat of the fire was the caged cardboard store. He too had attended the
scene of the fire and assisted in the initial excavation. In his opinion the most likely
explanation was fire started as a result of a naked flame rather than a smouldering
cause, such as a lit cigarette. He agreed with ]Mithat a lit leaflet could ignite
cardboard within seconds or almost instantly. Whilst he acknowledged that in very
particular circumstances it may be possible to start a fire using a lit cigarette, having
read the transcripts of the evidence given by both juveniles it was apparent that neither
of them was saying that any cigarette butt that they had been smoking had rolled under
the left-hand door or could have rolled under the left-hand door.

In any event both girls were saying that their cigarettes were completely extinguished
and had been smoked virtually down to the filter. opinion that the cause of the
fire was due to a naked flame was supported because of the timing of the events and
that the girls were at the doors when the first signs of smoke can be seen. All of this
points towards a naked flame ignition rather than a smouldering source.

a another forensic scientist who had been investigating fires longer
than was essentially of the same view, particularly with regard to the timings of

ent of the fire. He had been instructed by the solicitors then acting from
ee respect of the criminal charges but had not been provided with copies of
the girls’ police interview records to understand precisely what they were alleging had
happened. He had been asked to consider whether or not the fire could have been
potentially caused by a discarded lit cigarette igniting combustible materials. He was
advised (ho cigarttc was dropped on the floor and it either was rolled or
was kicked under the rear door. However, he agreed when giving evidence that if the
explanation about a lit cigarette rolling under the door is ruled out than that would feave
only one other potential source of ignition. Namely, the use of a naked flame in the form
of a lit leaflet pushed under the door.

He did not attend the scene and carried out a paper review but then also carried out his
own experiments. He purchased a number of cigarettes including those which were
apparently being smoked by the girls at the time. He lit seven whole cigarettes and
placed them on top of cardboard but on no occasion did they ignite a fire. For the eighth
cigarette he created what was described as a cardboard sandwich with some paper
wedged between them. He then inserted a lit cigarette horizontally into the package and
blew on it several times. After about three and a half minutes there was an ignition and a
flaming fire started. Unfortunately he did not record how many times he blew on the
cigarette or for what length of time nor with what strength. Having completed this
experiment, he thought as he demonstrated it was possible in some circumstances for a
fire to be started and therefore did not do any further experiments including control
experiments or putting a lit cigarette in contact with cardboard and/or paper is a different
angle. Nor did he use cigarettes that have been smoked virtually down to the filter as
was described in this case. This is important because the experiment that he video

recorded when a fire was ignited indicated that at least half of the cigarette had to be
burnt before a fire could start. A virtually completely smoked cigarette would have very
little fuel in the sense of tobacco to burn and would self extinguish within a much shorter
space of time. Apparently, the CPS decided to discontinue the prosecution and offer no
evidence based on the contents of his report.

The court instructed another independent expert called | He was a very
senior ex-Assistant and Acting Chief Fire Officer. He started investigating fires in 1984
and became a specialist fire investigation officer in 1993. He was the lead instructor for
fire investigation for Derbyshire Fire and Rescue Service, as well as teaching police
officers and scenes of crime officers about the process of fire investigation. He passed a
number of examinations relevant in the fire service and was a member of the Institute of
Fire Engineers. He investigated a large number of both fatal and non-fatal fires. He felt
that the only credible way that the fire started was by the application of naked flame. He
too took into account the timing of the events and pointed out that even if a discarded lit
cigarette from the girls had managed to find its way under the door it would have taken
much longer for any fire to have started than the evidence clearly shows in this case.

The expert evidence clearly indicates that the only credible explanation for the start of
the fire is the introduction of a naked flame under the door into the cardboard storage
area.

The fire itself took hold quite rapidly despite attempts by the owner and indeed others to
try and extinguish the initial flames in the cardboard storage area. They had spread to
the ceiling and across to the racking on the other side and ignited materials there which
in turn had spread. There was a significant amount of combustible material. The
premises were evacuated of all persons and on arrival one pump went to the back of
PHW and the other to the front. The rear emergency doors where the fire started was
designated as sector 1 in fire service terminology and the front of the building as sector
2. Initially crews wearing breathing apparatus (BA) were sent in to sector 1 in order to try
and fight the fire but also carry out a reconnaissance mission. They reported back that
the conditions were very cramped and there was an enormous amount of smoke being
generated by the fire.

The span of command at a fire like this has an overall incident commander. Depending
upon the nature and size of the fire they may have an operations commander as well as
a logistics commander. The various designated sectors will each have sector
commanders. The incident commander will set the overail strategy for fighting the fire
which is then actioned by the operations commander. The individual sector commanders
have responsibility for fighting the fire in their area and for the health and safety of the
firefighters involved as well as members of the public. Where BA crews are used there
will also be what is known as an Entry Control Officer who also operates the Entry
Control Board. This can be written on with a black chinagraph pencil but also has
telemetry connections with the BA crews’ equipment. In this case, considerable amounts
of pressurised smoke poured out of the building from both the front and the rear. Jets of
water were applied to the front of the premises from early on but there was no ingress
into the building by BA wearers.

As the afternoon progressed the sector commander in sector 1 appointed an overall
sector safety officer but also appointed a second safety officer with a particular role. He
had formulated a plan that BA wearers could enter via the emergency exit doors in
sector 1, go up a short flight of about six steps and fight the fire from the top of that area
but go no further. They were to be within visible sight or to be contacted audibly at all
times. They could then direct jets of water to particular hotspots. Crews were given
radios and thermal imaging cameras to assist. In addition because of extremely hot
conditions both outside but particularly inside he set a maximum wear of 20 minutes.
Over the afternoon there were some 40 entrances and exits by BA crew teams. In
addition there was a specific entry control officer who had the responsibility of operating
what is known as the entry control board. This role was carried out in the afternoon by a
firefighter. He kept an eye on the 20 minute time limit and notified the second safe

officer when crews needed to be withdrawn. Overall, during the afternoon crews had self
withdrawn on several occasions due to the deteriorating conditions. In addition they had
been withdrawn by the second safety officer wno could observe the conditions himself
but from the outside. The entry control board itself has what is known as telemetry with
the BA wearers equipment. On occasions this can be lost or can be intermittent but this
would not automatically trigger any emergency response.

Over several hours, the conditions periodically changed in that there would be periods
when less smoke came out of the building but other periods when significant amounts of
pressurised smoke emanated from the building. In sector 1 they had managed to take
down boarding across a disused window at the back of the building and make an entry
into that compartment so that firefighters could be positioned on a platform immediately
outside the building spraying a jet of water inside. They also managed to gain access to
a protected staircase on the other side of the building in what became sector 4 and cut a
hole in roller shutter doors covering the other set of disused emergency exit doors that
had apparently been covered up with racking in the PHW premises. From there they
deployed a fixed ground monitor. This is a static jet of water that is not controlled by
firefighters themselves.

It was recognised this was a fire that was going to burn for some considerable time. The
day shift would change at about 19:00 hours and new crews would be attending in order
to take over from their colleagues who had been fighting the fire all afternoon. At the
front of the premises had been positioned what is known as an aerial platform. This is
able to deliver significant quantities of water onto a fire usually from a height. Depending
upon the availability of water this equipment can fire a jet which is many times more in
the terms of quantity than an ordinary 45mm hose. The building itself had on one side a
coffee shop and on the other a hotel. There was concern to stop the fire spreading. At
one point it was noticed that fire had apparently spread to the first floor and at about
19:18 hours there was a direction that all BA crews be withdrawn from the premises
whilst the aerial platform directed water into the first floor.

This appeared. to be successful and at about 19:30 hours the incident commander and
his other senior officers met and decided that BA crews could be redeployed into the
premises in sector 1 because there was no noticeable effect at the rear from the
deployment of the aerial platform at the front of the building. Consequently, at 19:35
hours to firefighters wearing BA equipment were deployed into the building and they left
at 19:52 hours. The BA crew team leader did not recall being told about the 20 minute
maximum wear but in any event heard a shout for them to leave and they did so and
took with them their hose. Usually they would have a debrief with either the entry control
officer or the sector commander but this did not take place. It would seem that sometime
after about 19:30 hours the sector commander of sector 1 handed over to his
replacement and maintained that he gave a thorough brief explaining in particular the
role of the second safety officer outside the sector 1 entrance keeping an eye on the
firefighters at the top of the stairs. The second safety officer himself told the court that he
briefed three colleagues on his role because originally he thought one of them was
going to take over his particular tasks. Likewise the entry control officer says that he
handed over what he had been doing that afternoon.

The incoming sector commander, entry control officer and sector safety officer gave
evidence and did not seem to have either heard or understood about the particular
safety measures for BA crews entering via sector 1. It is a matter of fact for the jury to
decide but on the evidence that they have heard they could come to the conclusion that
whatever brief was given to the deceased and Firefighter [J was not the same as the
earlier briefs. There was no second safety officer appointed. The jury were played CCTV
recordings of the exit of the firefighters at 19:52 hours and then the deceased and
Firefighter [J preparing to go in at 20:04 hours.

The sector 3 commander decided to redirect the aerial platform jet into the front ground
floor main entrance of the premises but indicated that he would not have done so had he
realised that there were BA crews entering via sector 1. It seems that he decided to do

this without any specific instruction from the operations commander who told the court
that he gave no such authority or instruction. Both the operations commander and the
incident commander told the court that in fact they would have had no concern about
this because they knew something of the structure of the internal part of the premises in
that there was a dividing wall between the front of the shop in the rear storage area.
Ideally sector commanders should communicate with one another about their activities
in case they may affect the firefighting operations in another sector.

The deceased and his colleague Firefighter I had arrived as a member of the new
evening shift and formed the BA team. They were directed to go to sector 1 and went
under air at 19:59 hours and then went into the building at 20:04 hours. If they had been
subject to a 20 minute maximum wear then they should have been exiting the building at
20:19 hours. In the event relief crew was sent in at 20:26 hours and they believed that it
took them a couple of minutes to find the deceased and Firefighter They had
gone to the top of the stairs, turned left and had been found in the area outside what
was described as the post room and at the base of a flight of stairs up to a mezzanine
level. Visibility inside was virtually zero. The relieving crew had followed in the hose. The
deceased was the leader of the BA crew and apparently walked towards the leader of
the relieving crew and thrust the hose in his chest and said words the effect that they
were getting out of there.

It was thought that this was about 10 metres inside the building. It was only a few feet
away from the top of the stairs and the exit. Firefighter [had no recollection of this
at all and in particular seeing and being relieved by the new BA crew. However, he did
remember the post room and the fact that the deceased had gone virtually to the top of
the stairs leading to the mezzanine when Firefighter JJ explained that he was feeling
extremely hot and he thought that they should leave the premises. His recollection was
that the deceased came down the stairs and they tried to follow their hose out but could
not do so. They were crawling on their hands and knees and he recognised that he was
suffering the cognitive effects of extreme heat. At one point he recognised the need to
press the emergency button on his ASDU equipment but simply could not manage to do
so even though he knew fully how to operate it. It seems that he suffered a very painful
burn to his left hand and removed his glove.

The BA crew which had gone in to relieve the deceased and Firefighte lll very
quickly came to the conclusion that the circumstances inside were not as described to
them when they were briefed and they decided to withdraw from the building and were
seen doing so at 20:32 hours. When they exited they were mistaken for been the
deceased and Firefighterfb. On leaving the building they thought they heard cries
for help.

The BA equipment also known as ASDU has a telemetry system to make contact with
the entry control board. This will show the rate of consumption of their air. It also has a
movement sensor system so that if the operator does not physically move for a period of
36 seconds it will set an alarm off. The equipment can also set off what is known as a
low pressure alarm when only a limited amount of air is stil! in the BA cylinder. In this
case, the deceased's low pressure alarm was sounded at 20:30 hours and then motion
alarm itself 20:35 hours. This coincided with the time that the deceased actually ran out
of air completely.

Firefighter low pressure alarm sounded at 20:32 hours. A BA emergency was
called at 20:34 hours. A BA crew that had been sent to reposition the ground monitor at
sector 4 heard what they thought was the sound of colleagues within the compartment.
By crawling on his hands and knees he came across Firefighter Il began to rescue
him with the assistance of his colleagues. This coincided with the initiation of the BA
emergency and it is thought Firefighter was rescued at 20:35 hours. Other
colleagues came to assist but it was not until 20:41 hours that the deceased was found
a short distance away and removed from the fire compartment outside. He was stil!
wearing his facemask but not his helmet. He had also lost a glove and a boot. Attempts
were made to resuscitate him at the scene but with no success. He was taken to the

Manchester Royal Infirmary where further efforts at resuscitation also proved
unsuccessful and he was pronounced dead at 21:21 hours.

After his death was reported to me, | authorised a forensic post-mortem examination
carried out by a very experienced forensic pathologist. | also authorised a second post-
mortem examination carried out by another forensic pathologist. It was apparent the
deceased had suffered no significant traumatic injuries and examination of his heart and
other organs demonstrated no abnormality. The first Forensic Pathologist,

gave evidence and in summary terms expressed the opinion that the cause of death
should be described as 1(a) Heat exhaustion and hypoxia.

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) It is suggested that all Fire and Rescue Services (FRS’s) should consider the
implementation of measures to reduce the risks associated with the physiological
affects of working in a hot environment. In particular consideration should be given
to:

Duration of wears under breathing apparatus;

Having regard to all relevant factors including, for example the weather, previous
exertions of BA teams and individual circumstances;

Training and guidance for all operational personnel to recognize the effects of heat
both on themselves and on their colleagues and the appropriate steps to take
upon such recognition, including withdrawal and self withdrawal.

Training and guidance for all operational personnel to have the ability and
confidence to ensure the withdrawal of others who may be adversely affected by
heat whether by calling a BA emergency or otherwise appropriately.

Training and guidance for all operational personnel to have the ability and
confidence to withdraw themselves by whatever means appropriate including
activating the ADSU.

It is suggested that all FRSs should consider the implementation of measures to
reduce the risks associated with the loss of communications at operational incidents.
For example, to include safety control measures to ensure BA teams can be
withdrawn from the risk area if needed.

It is suggested that all FRSs should undertake a review to ensure the adequacy of
standard operating procedures, guidance and training of the handing over and
taking over of roles at incidents to ensure all the key areas of information, including
safety control measures, are captured and shared.

It is suggested that all FRSs should ensure that significant hazards and any safety
control measures are the responsibility of the incident commander and should be
recorded within each sector, to ensure visibility to all on the fireground, and
passed/copied for use by the the incident commander/command team to assist on
the analytical risk assessment.

It is suggested that all FRSs should undertake a review to ensure the adequacy of
standard operating procedures, guidance and training in the appropriate use of
thermal imaging cameras to include the limited extent to which they can be relied
upon to measure ambient temperature.

(6) It is suggested that all FRSs should undertake a review to ensure the adequacy of

standard operating procedures, guidance and training in the deployment of aerial
monitors to ensure the safety of any personnel within the risk area is not
compromised.

It is suggested that all FRSs should undertake a review to consider the
circumstances in which inspections should be carried out under section 7(2)(d) of
the Fire and Rescue Services Act 2004.

It is suggested the above mentioned steps be undertaken jointly by Fire and Rescue
Services and the FBU or other Health and Safety Representatives on the Health and
Safety Committees.

It is suggested that the Secretary of State for the Home Department considers
measures to ensure that:

fire risk assessors are adequately trained and qualified so as to be competent in the
role, and

the responsible person has the means to verify the competence of any person
holding themselves out to be a fire risk assessor.

(10) It is understood that there are some 45 Fire and Rescue Services and the findings
of the inquest need to be disseminated down to them all. The pressure is upon
them to find their own solutions to problems against the backdrop of financial

pressures. The Home Office now leads on fire issues and there has been ever

increasing decentralisation. Whilst this is not without merit there appear to be
difficulties in ensuring that services are meeting expectations and a means of
disseminating national learning.

It is suggested that consideration is given to being able to mobilise a national and
consistent approach to sharing the learning and testing so that it can be shown to
be received, understood, actioned and embedded.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and your
organisation 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 Friday 12 August 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 Interested Persons. | have
also sent it to organisations who may find it useful or of interest.

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.

8 June 2016 Nigel Meadows
HM Senior Coroner
Manchegter City Area

Responses

2 responses 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.

Response from Devon Somerset Fire Rescue Service (PDF)

RECEIVED
29 JUL 2016

DEVON &
SOMERSET

FIRE & RESCUE SERVICE

Mr N Meadows Service Headquarters
Senior Coroner The Knowle
Manchester (City) Coroner's Office Clyst St George
PO Box 532 Exeter
Manchester Town Hall Devon
Albert Square EX3 ONW
Manchester
M60 2LA
Your ref : Regulation 28 Report Date : 27 July 2016 Telephone : 01392 357227
Our ref: NM/CB Please ask for : Area Manager Manning Fax:

Website : www.dsfire.gov.uk Email if Direct telephone : 014392 357225

Dear Mr Meadows,

| am writing in response to your Regulation 28 report to prevent future deaths in
respect of Stephen Alan HUNT of Greater Manchester Fire and Rescue Service
dated 8 June 2016.

Devon and Somerset Fire and Rescue Service (DSFRS) has carefully considered
the report and your matters of concerns that are expressed in questions 1 - 7 posed
to all individual fire and rescue services. Our responses to these concerns are
detailed in the table below.

Yours sincerely

Area Manager

Tel. 01392 872200 Chief Fire Officer Lee Howell QFSM FIFireE

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002228 26EL0 “IAL

Response from Respondent Not Named (PDF)

ECEIVED

Shailesh Vara MP

ini Parliamentary Under-Secretary

Ministry 0.6 MAY 2016 of State for Justice
ofJustice

Nigel S. Meadows

H.M. Senior Coroner

H.M. Coroner’s Office Your ref: 01632/2013

P.O. Box 532 MoJ ref: ADR32818

Manchester Town Hall

Albert Square bn

M60 2LA Z f April 2016

Dow Ih GaLot

INQUEST INTO THE DEATH OF STEPHEN HUNT, DECEASED

Thank you for your letter of 30 March, addressed to the Lord Chancellor and Secretary of State for
Justice, regarding the inquest you are holding into the death of the above named. In particular, you raise
the issue of legal aid funding for two individuals who you have identified as interested persons. | am
therefore replying as the Minister responsible for legal aid.

| have seen the recent judgment handed down by Mr Justice Leggatt, which confirmed that Article 6 of the
ECHR was not engaged by the circumstances of this case and that the Director of Legal Aid Casework
therefore had no power to make legal aid available to the two individuals via the legal aid exceptional
funding scheme. | also noted carefully the comments made regarding the duty on coroners under the
Coroners (Inquests) Rules 2013 to protect witnesses from self-incrimination.

Under the legal aid scheme decided by Parliament as set out in the Legal Aid, Sentencing and
Punishment of Offenders Act 2012, funding for representation at inquests is only available for family
members in the form of exceptional case funding where, broadly, a refusal to fund would breach Article 2
of the ECHR or where the Director of Legal Aid Casework has made a Wider Public Interest
Determination in relation to the inquest and the family member. Under the scheme decided by Parliament,
legal aid is not available for representation of non-family members and there are no current plans to
change this scheme.

Finally, | must point out that applications for legal aid are considered individually by the Legal Aid Agency
and decisions are made by the Director or Legal Aid Casework independently of Ministers. The law does
not allow Ministers to intervene. It is important that these decisions are, and are seen to be, free from

political and Government influence.
Jowt serere &
(ae —
SHAILESH VARA ee

T 020 3334 3555 E general.queries@justice.gsi.gov.uk 102 Petty France
F 0870 761 7753 www.gov.uk/moj London
SW1H 9AJ

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