Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0219, written 23 May 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 May 2016 |
|---|---|
| Reference | 2016-0219 |
| Deceased | Sadie Peters, Joseph Peters and George Peters |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Child Death (from 2015) · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquests Touching the Deaths of Sadie PETERS, Joseph PETERS and George PETERS A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Great Britain • • • Service 1 CORONER – General Secretary of The Showmen’s Guild of – Chairman of The Caravan Club – Chief Fire officer – Surrey Fire and Rescue Richard Travers HM Senior Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST The inquest into the deaths of Sadie PETERS, Joseph PETERS and George PETERS was opened on the 8th January 2015 and was resumed on the 17th May 2016 and concluded that same day. In the case of each death I found the cause of death to have been: 1a. Inhalation of fire fumes. In the case of each death I concluded with a short form conclusion of ‘Accidental Death’. 4 CIRCUMSTANCES OF THE DEATH During the winter months Sadie Peters lived together with her three sons, , Joseph aged 6 years and George aged 14 months, with her husband and the children’s father home situated at The Plantation, Lingfield, Surrey. in a permanent mobile was a Rtdoc/04037-2014/Reg28/23-5-2016 1 showman and came from a long line of showmen. Other members of his family and fellow showmen families also lived in permanent caravans at the Plantation. At about 01.30 hours on the 30th December 2014 was awoken by sounds outside his caravan. When he went . Tragically and the couple’s eldest child outside to investigate he discovered that caravan was on fire. He made valiant attempts to save the people inside and managed to rescue his brother Sadie Peters and the two youngest children, Joseph and George, did not manage to escape and all three died in the fire. I heard evidence that the fire started in a small extension to the caravan that housed a solid fuel burner and that this burner was the most likely cause of the fire. I heard that it became apparent from a close examination of the remains of the fire that there was no smoke detector fitted inside the caravan. Further, I was told that had a smoke detector been fitted inside the caravan the occupants would have been warned about the fire at an early stage and that it was more likely than not that the outcome would have been different. 5 CORONER’S CONCERNS Whilst I do not underestimate the work done by Surrey Fire and rescue Services in making people aware of the importance of using smoke detectors, whether in a building and or a caravan, and the full engagement of The Showmen’s Guild of Great Britain in that work, during the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are: Fitting of Smoke Detectors in all Mobile and Static Caravans 1. Consideration should be given to maintaining or developing any existing programmes and, where appropriate, creating new programmes which are designed to raise awareness amongst people using or living in caravans, whether mobile or permanent, of the importance of fitting and maintaining a fully functioning smoke detector inside the caravan. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I Rtdoc/04037-2014/Reg28/23-5-2016 2 believe that the persons listed in paragraph one above are in a position to draw these concerns to the appropriate authority in place who has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following: Great Britain 1. 2. 3. – General Secretary of The Showmen’s Guild of – Chairman of The Caravan Club – Chief Fire officer – Surrey Fire and Rescue Service 4. 5. The Chief Coroner (on behalf of the family) Signed: Richard Travers DATED this 23rd May 2016 Rtdoc/04037-2014/Reg28/23-5-2016 3
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.
Tel: 01737 242444 Fax: 01737 227624 na: Website: www.surreycc.gov.uk/fire SURREY Surrey Fire & Rescue Service HM Coroner’s Court Headquarters Mr Richard Travers St D vid Station Approach avies . 70 Wray Park Road Woking Reigate Surrey @U22 7AP Surrey, RH2 OE) 29" July 2016 7” Regulation 28 Report — Action to Prevent Future Deaths Mrs Sadie PETERS, Joseph PETERS and George PETERS Regulation 28 Report — Action to Prevent Future Deaths Thank you for your letter dated 17"" June 2016 written under regulation 28 of the Coroners (Investigations) Regulations 2013 Concerning the tragic death of Mrs Peters Joseph Peters and George Peters at The Plantation, Lingfield, Surrey on 30th December 2014. | would like to take this opportunity to record my deepest sympathy to the family and friends of Peters family and to take the opportunity to thank you for your thorough review of the events relating to the fire at The Plantation. We welcome your recommendations and comments around the work already completed by Surrey Fire and Rescue Service’s (SFRS) and the Showmen’s Guild of Great Britain. | have set out the Surrey Fire and Rescue Service’s (SFRS) response below. The matters of concern that you identify as relating to SFRS and associated recommendations are detailed in bold, and the SFRS’s response is shown in italics. Fitting of smoke detectors in all Mobile and Static Caravans 1 - Consideration should be given to maintaining or developing any existing programmes and, where appropriate, creating new programmes which are designed to raise awareness amongst people using or living in caravans, whether mobile or permanent, of the importance of fitting and maintaining a fully functioning smoke detector inside the caravan. | As you are aware following this and other incidents on static mobile home sites in Surrey, SFRS working with the Showmen’s Guild of Great Britain, private site owners and local authorities landlords of council | controlled site have visited all identified sites in Surrey offering and conducting community fire safety visits and fitting 1000s of free smoke alarms and where required carbon monoxide alarms. We also continue to take a partnership agency approach that focuses on the most vulnerable members of these sites via a new risk assessed database that brings together NHS and other agency data on all properties across Surrey. | Printed on recycled paper surreycc.gov.uk | We are now planning to continue to raise and increase awareness of the importance of fitting and maintaining smoke alarms by working with the relevant agency and site owners to have a continuous message to those using or living in mobile or permanent caravans. It is planned that this will be in place by October 2016, but it should also be recognised that this also part of normal community safety work of raising the public awareness to a range of safety issues. We also feel it is important that your issues are raised at a national level, to this end we have brought your recommendation to the attention of all Chief Fire Officers in England and Wales Should you require any further information then please do not hesitate to contact me.
200084
Patron: HRH The Prince Philip, Duke of Edinburgh ke kt
President: The Earl of Leicester
Chairman: G J Chamberlain
Director General: N D J Lomas
East Grinstead House
East Grinstead, West Sussex RH19 1UA
Telephone: 01342 326944
Fax: 01342 410258
www.caravanclub.co.uk
NL/TE/3203 Direct Dial: 01342 336700
5 July 2016
Dear Mr Travers
Re: Mrs Sadie PETERS, Joseph PETERS and George PETERS
Regulation 28 Report to Prevent Future Deaths
Thank you for your letter of 10 June 2016 addressed to Mr Chamberlain, The Club Chairman. | have
spoken with Mr Chamberlain and am pleased to respond on his behalf.
The Caravan Club was very sorry to learn of this case and the sad deaths of Sadie, Joseph and George
Peters.
The Caravan Club is a members’ Club for owners of mobile touring caravans and motorhomes. We do
provide a good deal of advice for our members on how to caravan safely.
The Club does offer advice and guidance to its members with regard to fire safety, and this includes a
recommendation to fit a smoke detector complying with BS EN 54-7 to all members’ outfits.
We do periodically remind members of the need to protect against the risk of fire, and | will be happy to
build such a reminder of this into our monthly members’ magazine, and other suitable publications.
1am advised by our technical team that the absence of a smoke detector was particularly unfortunate. It
has been longstanding practice (since May 1989) for all new touring caravans which are subject to the
National Caravan Council’s Certification Scheme (all those made by NCC member manufacturers) to be
fitted with a smoke detector. This would mean around 95% of all new caravans sold in the UK, | would
estimate. It has further been a requirement from the same date that all second-hand touring caravans
sold by NCC member dealers be so fitted. As such, the majority of touring caravans in use would, |
expect be fitted with smoke detectors.
In terms of the constructional standards for caravans of all types (touring, static and indeed park
homes), the representative body for the UK industry, the National Caravan Council would be better
placed than The Caravan Club to take actions, and should, in my view, be included in the circulation of
the Report.
Mr R Travers
HM Coroner’s Court
Station Approach
Woking
Surrey
GU22 7AP
Corporate Name and Registered Office: The Caravan Club Limited, East Grinstead House, East Grinstead, West Sussex RHI9 ILA Registered in England No 646027
lam in regular contact with the Director General of the Camping and Caravanning Club, the National
Caravan Council {also represent vehicle manufacturers and dealers) and the British Holiday and Home
Parks Association (BH&HPA). | will make sure your letter is shared with these organisations.
Thank you for bringing the matter to our attention.
Yours sincerely
Nick Lomas
Director General
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