Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0451, written 12 Dec 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 Dec 2016 |
|---|---|
| Reference | 2016-0451 |
| Deceased | Ellen Kelly |
| Coroner | Edwin Buckett |
| Coroner area | Inner North London |
| Category | Other related deaths · 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
Ellen Eileen Margaret Kelly (died 16.7.2016)
THIS REPORT IS BEING SENT TO:
Mr Mike Cooke
Chief Executive
London Borough of Camden
5 Pancras Square
London N1C 4AG
1
CORONER
I am: Edwin Buckett
Assistant 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 20th July 2016 Senior Coroner Hassell began an investigation into the
death of Ellen Eileen Margaret Kelly who died aged 86 on the 16th July,
2016 at St Mary’s Hospital Paddington.
The investigation concluded at the end of the inquest on 12th December
2016 conducted by myself, Assistant Coroner Edwin Buckett.
I made a determination at inquest that the deceased died as a result of
smoke inhalation injuries sustained as a result of a house fire at
which occurred on the 7th
July, 2016.
4
CIRCUMSTANCES OF THE DEATH
On the 7th July, 2016 Ellen Eileen Margaret Kelly had a cigarette at her
1
home address
which she did not fully extinguish. She placed it into a carrier bag
containing other cigarette butts and this caught fire. An extensive fire then
occurred at the flat and she suffered smoke inhalation injuries and died
on the 16th July, 2016 at St Marys Hospital, Paddington.
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.
Evidence was given by Watch Manager
London Fire Brigade that:
from the
1.
Camden.
is a block owned by London Borough of
2. At the time of the fire, the front door of Flat 13 was left open whilst
the occupant went to raise the alarm. This caused the fire to
spread more quickly than would have been the case had the door
been shut. It also caused smoke to disperse in the common parts
of the building.
3. Another family was trapped in Flat 15 (above Flat 13) until the
London Fire Brigade attended.
4. The front door of Flat 13 should have been fitted with a self-closing
mechanism but was not.
5. Other front doors in the block identified by the London Fire Brigade
when they attended were not of a suitable standard in that they did
not comply with the 30 minute fire resistant British Standard.
I consider that it is likely that there are front doors of flats within Kilburn
Gate which do not have:
a. A proper self-closing mechanism
in accordance with
legal
requirements as this was the case with the door to Flat 13, and
b. Do not comply with the relevant British Standard, in that they are
not fire resistant for 30 minutes or more.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and/or your organisation have the power to take such
action.
2
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 February 2017. 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 following:
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
London Fire and Emergency Planning Authority
, Commissioner, London Fire Brigade
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 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 12.12.2016 SIGNED BY ASSISTANT
CORONER EDWIN BUCKETT
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.
oe = = 2 Camden Date: 24" Ja eealtes Londionldemucn of Coarden Supporting Communities Directorate Town Hall Judd Street London, WC1H 9JE Mr Edwin Buckett Phone: 0207 974 6630 Assistant Coroner www.camden.gov.uk Inner North London St Pancras Coroner's Court Camley Street London N1C 4PP uy 27 sane |!) Dear Mr Buckett sR BERmeccdeewseewwnnee Response to Coroner’s Regulation 28: Prevention of Future Deaths report Ellen Eileen Margaret Kelly The London Borough of Camden takes its responsibilities for fire safety in its Housing stock very seriously and we will take action to address the concerns that have been raised. The Council already has a significant programme in place to improve fire safety in council housing. We hold regular meetings with the Fire Service to review safety and risk assessments and a £5m programme of fire safety works to 4,500 high priority housing properties has already been completed. The scope of the works is comprehensive and includes renewal or upgrading flat entrance doors to “FD30s” standard, signage, emergency lighting installations and fire stopping. The work aiso includes review and attention to surface spread of flame in means of escape provision. The council employs specialists to assist in specification and delivery of the programme and has appointed a fire safety advisor (recruited from the London Fire Service) to help assess risk and advise on fire protection. For 2017/18, the projected spend on fire safety is over £10m and is again concentrated on higher risk properties. The works include upgrading or renewing flat entrance doors to FD30S standard, renewal or upgrading of communal doors, installing fire alarm system to street properties, installing emergency lighting and fire stopping (compartmentation). In addition, the council's Better Homes (building fabric and communal repairs) programme will incorporate fire safety works on each block where work is undertaken. In regards to Kilburn Gate, fire safety works have been prioritised and have been tendered. This work includes installing new FD30s flat entrance doors incorporating door closers, renewal of communal intake doors and redecoration of communal areas to Class 0 fire resistant standard. We are currently consulting with Leaseholders in the block (as required by’section 20 of the Landlord and Tenant Act 1985) and this consultation is due to be completed in mid-February and the works are expected to commence in March 2017. The council promotes fire safety to residents through our Newsletter and on the Camden website which also contains links to the London Fire Brigade website advice pages. We have also provided fire safety awareness training to our estate services and other housing staff. If you have any query on the above please do not hesitate to contact me. Yours sincerely, at | Wu U (Acting) Director Property Management Supporting Communities
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.