Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0157, written 15 May 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 May 2017 |
|---|---|
| Reference | 2017-0157 |
| Deceased | Blaise Alvares |
| Coroner | Nicholas Rheinberg |
| Coroner area | Wiltshire and Swindon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
NICHOLAS LESLIE RHEINBERG
Assistant Coroner for Wiltshire and Swindon
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Fire Officers’ Association
9-11 Pebble Close
Amington
Tamworth
Staffordshire
B77 4RD
CORONER
lam Nicholas Leslie Rheinberg, Assistant Coroner for Wiltshire and Swindon
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.
http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 11" November 2016 an investigation into the death of Sharon Ann Soares was commenced
and on 5"" January 2017 an investigation into the death of Blaise Sanito Alvares was
commenced. Sharon Soares who was aged 30 died on 9" November and her husband Blaise
Alvares who was 33, died on 23" December 2016. Although their deaths occurred more than a
month apart, both died as a result of injuries sustained during a fire at their home at 141
Manchester Road, Swindon on 6" November 2016. At the inquest hearing today | concluded that
both individuals had died as a result of an accident.
CIRCUMSTANCES OF THE DEATH
At some time after 11 pm on Sunday 6" November 2016 a fire broke out in the downstairs living
room of 141 Manchester Road, Swindon. At the time there were 7 individuals in the house, a
three bedroomed terraced property. The fire was intense and produced thick choking smoke,
substantially reducing visibility, a problem which was exacerbated by the fact that the electricity
supply tripped out eliminating artificial lighting. The conclusion of a thorough fire investigation
report was that the probable cause of the fire was the ignition of combustible materials including
curtain, clothing and bedding materials by exposure to naked flame from a bio ethanol heater.
One of the seven individuals within the house managed to escape through an upstairs window.
However, the remaining six were trapped within the property and had it not been for the prompt
actions of members of the public and the attending fire brigade, all six would have perished. As it
was Mrs Soares and Mr Alvares, although rescued died subsequently from their injuries.
CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. —
Evidence was heard at the inquest to the effect that this was at least the second occasion of
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
fatalities attributable to a Bio Ethanol burner with a previous death reported in Uttoxeter, together
with a substantial number of previous accidental injuries, including a series of events in
Staffordshire.
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action to address the concern highlighted above by publishing safety warnings in
relation to the use of bio ethanol heaters indoors,
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
12" July 2017. I, the Assistant 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
| am sending a copy of my report to the Chief Coroner and to the following Interested Persons
namely the family of the deceased and also to Station Officer Bagnall who was the officer who
investigated the fire in question.
{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 Assistant Coroner, at the time of your response, about
the reiease or the publication of your response by the Chief Coroner.
9 | Dated this 15” day
Signature
HM Assistant Coroner for Wiftshire and
Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
Tel 01722 438900 | Fax 01722 332223
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