Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0247, written 12 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jul 2016 |
|---|---|
| Reference | 2016-0247 |
| Deceased | Steven Billington |
| Coroner | Jennifer Leeming |
| Coroner area | Manchester (West) |
| Category | Other 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.
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 THIS REPORT IS BEING SENT TO: 1. The Rt Hon Theresa May MP, Home Secretary 2. The Rt Hon Greg Clark MP, Secretary of State for Communities & Local Government 1 CORONER I am Professor M Jennifer Leeming H M Senior Coroner, for the Coroner Area of Manchester West 2 CORONER’S LEGAL POWERS I 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 25th March 2015 I commenced an investigation into the death of Steven Thomas Billington, aged 49 years. The investigation concluded at the end of the inquest on 4th July 2016. The conclusion of the jury following inquest was ‘an accident from a deliberate act of putting his clothing on a maiden and placing the maiden in front of the unprotected gas fire resulting in the unintentional ignition of the clothing.’ 4 CIRCUMSTANCES OF THE DEATH Steven Thomas Billington died on 25th March 2015 as a consequence of inhaling products of combustion arising from a fire at his home address Flat 3, 12 Bradford Avenue, Bolton. The jury concluded, as can be seen above, that the fire occurred when clothing that had been placed on a maiden in front of a gas fire to dry ignited. Mr Billington’s flat was one of a number of flats within a premise that had been converted into separate units of living accommodation. As the relevant Fire Safety Orders require, the premises were fitted with a mains powered alarm system. However the on/off control-switch for the system was unprotected and was situated in an accessible communal part of the premises. At some stage the system had been turned off at that switch with the result that the alarm could not and did not give warning of the fire. 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. 1 The MATTERS OF CONCERN are as follows: The on/off control-switch for the mains powered alarm system was not protected and was therefore able to be switched off. Evidence was given that the relevant regulations do not require the on/off control for such a system to be rendered inaccessible to all but authorised persons. Further evidence revealed that it would be a simple matter to protect the control by it being placed, for example, in a locked cupboard and this would have no detrimental effect as the control panel for the system that allows it to be reset in the event of false alarm is separately situated from the on/off control-switch. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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 6th September 2016. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Daughter I have also sent it to the following who may find it useful or of interest: Peter O’Reilly, County Fire Officer & Chief Executive, Greater Manchester fire Service. Landlord of premises. 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 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. 9 Dated Signed 12th July 2016 Professor M Jennifer Leeming 2
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.
ae Gavin Barwell MP Minister of State for Housing and Planning and Minister for London Department for Communities and Department for Communities and Local Government Local Government Fry Building 2 Marsham Street London : . SW1P 4DF Jennifer Leeming HM Senior Coroner - Manchester West Tel: HM Coroner's Court Paderborn House Howell Croft North www.gov.uk/dclg Bolton Greater Manchester Our Ref:2560044 BL1 1QY Your ref; MJL/HK/S-Billington Decl Plefessos Leanne) Thank you for your letter of 12 July to the Rt Hon Greg Clark MP which includes your report under regulation 28 of the Coroners (Investigations) Regulations 2013, in relation to the death on 25 March 2015 of Steven Thomas Billington in a fire at his home, in Your report was addressed to the Home Secretary as well as to Although your letter has been passed to me given my responsibility for Housing and Building Regulations, | am also replying on behalf of the Home Secretary. | was very sorry to read about Mr Billington’s death. | understand that the power supply to the fire alarm in the building had been switched off and that this may have contributed to his death. My officials have looked at the relevant standards for the installation of fire detection and alarm systems. It appears that the current guidance in British Standard 5839 already requires that isolators for fire alarm systems are appropriately secured against unauthorised tampering. Perhaps the system in question was an older system that did not meet the current standard. However, if the investigations of the fire and rescue service have identified a weakness in the standard, then this should be brought to the attention of the relevant committee at the British Standards Institution. The committee may need more information than is contained in your report. If you or the fire and rescue service need assistance in this respect, please contact my official x at my address, or email GAVIN BARWELL MP
Brandon Lewis MP Minister of State for Policing and the Fire Service 2 Marsham Street, Home Office are www.gov.uk/home-office Jennifer Leeming HM Senior Coroner - Manchester West HM Coroner's Court Paderborn House Howell Croft North Bolton Greater Manchester BET TQY 16 SEP 2016 Your Reference: MJL/HK/S-Billington | am writing to thank you for your recent letter to the Home Secretary and your report under regulation 28 of the Coroners (Investigations) Regulations 2013. | have seen a copy of the Minister of State for Housing and Planning’s response on behalf of the Home Secretary, and thought it only appropriate, as the Minister of State for Policing and the Fire Service and a former Housing Minister, to offer my own sincere condolences to the family and friends of Mr Billington. This must have been a particularly difficult and sad time for them. | trust you, or the Greater Manchester Fire and Rescue Service, will take the opportunity to discuss with British Standards Institution any further concerns that you may have. are a BRANDON LEWIS MP CC Gavin Barwell MP, Minister of State for Housing and Planning
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