Prevention of Future Deaths reports · 2017

Rasikaben Chauhan

Regulation 28 report to prevent future deaths, reference 2017-0194, written 14 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Jun 2017
Reference2017-0194
DeceasedRasikaben Chauhan
CoronerHassan Shah
Coroner areaNottingham
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

regulation 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Asra Housing Group - Nazarana Court
Chief Fire and Rescue Officer
Indian Hindu Welfare Organisation

CORONER

I am Hassan Shah, Assistant Coroner for the coroner area of Northampton.

CORONER'S LEGAL POWERS

I nfiake 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.

INVESTIGATION and INQUEST 
On the 30 December 2016 an investigation was commenced into the death of
Rasikaben Lallubhai CHAUHAN (84). The investigation concluded by way of inquest on
17 May 2017. The medical cause of death was la) Multiple burn injuries

—

CIRCUMSTANCES OF THE DEATH
Mrs Chauhan was an 84 year old lady living in a block of flats specialising in sheltered
accommodation for elderly people of south east Asian/Indian origin. On the 27*^
December 2016, Mrs Chauhan was in a chair facing her Hindu shrine when one of two
oil burning candles became dislodged from the shrine falling onto her clothes and fully
engulfing her in fire. The oil burner contained ghee (clarified butter). Mrs Chauhan was
wearing a sari type robe dress. The ghee and the sari were both factors which would
have caused Mrs Chauhan to become engulfed in flames very quickly. The
Northamptonshire fire and rescue station manager revealed in evidence that he does
have knowledge of several other incidents and that in some areas advice is being given
in relation to the use of battery powered candles.

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 could 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 not clear if any awareness about this specific risk has been raised at a local

or national level, with relevant community and religious organisations.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I  believe you AND/OR
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 9 August 2017. 1, 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 

~

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:-.
Son of deceased
Care Quality Commission
Northamptonshire Fire Station

Similarly, you are 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.

[DATE] 
14"'June 2017

[SIGNED BY CORONER]

Responses

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.

Response from Northampton County Council (PDF)
0 7 AUG 2017

pg »0«»C0Mro»DIAf flCSHU V|

Northamptonshire Coimty Coxmcil

PRIVATE AND CONFIDENTIAL

Mr H Shah
HM Assistant Coroner for Northamptonshire
110 Whitworth Road
Northampton
NN14HJ

Please ask for;

Tel:

Our Ref:

Your Ref:

Date:

DD/ss

HS/Chauhan

3 August 2017

If you have any difficulty in obtaining the above
telephone number please ring (01604) 797000 or
email enauiries@northantsfire.orQ.uk.

Dear Mr Shah

Re: Raslkaben Lallubhai CHAUHAN (deceased) - Regulation 28

I  am writing in response to your letter dated 14 June 2017 requesting us to provide information
required in your Regulation 28 Report to Action to Prevent Future Deaths.

In respect of the "Matters of Concern"

1) It is not clear if any awareness about this specific risk has been raised at a local or national

level, with relevant community and religious organisations.

National Awareness

Following the issue of the Regulation 28 letter and report to me, I  contacted the national prevention
lead for the  National  Fire  Chief Council (NFCC).  The NFCC is  the  professional  body that
represents Fire Chiefs across the country. The NFCC has an online communication tool known as
"communities"  which  allows  information  to  be  sent  to  all  UK  Fire  and  Rescue  Services.
Northamptonshire have, therefore, made the risks and circumstances which led to this  death
known to other UK Fire Services in order to alert them. We have received a number of responses
from other services highlighting work they have also carried out.  Examples of these are enclosed
with this letter.

The risk around the use of candles in the home and the cultural aspects associated with this are
well  known across the whole fire  and rescue sector and targeted  safety  advice features in
nationally driven campaigns supported by local action plans. The national Firekills Candle Safety
Campaign will take place specifically during the week of the 5 day Diwali celebrations in October
(16^ -22"^) and we will be fully promoting that campaign focusing on keeping clothing (including
Saris and scarves) from divas and other flames. I  include for your information, the following link to
the campaign calendar httD://www.cfoa.ora.uk/12Q29. This is just one example of a wide range of
targeted safety campaigns led by the Prevention and Protection Committee within the NFCC which
feature in local delivery plans providing fire, water and road safety advice to communities within
Northamptonshire.

Northamptonshire Fire and Rescue Service
Service Headquarters
Wootton Hall Park
Northampton, NN4 OJQ
w. www.northamDtonshire.QOV.uk
t.  01604 797000
f.  01604 797070

Northamptonshire
County Council

 In respect of "Actions that should be taken to prevent future deaths",

The Fire and Rescue Service Act 2004 requires  all  fire  and rescue authorities to undertake
prevention  activity.  At a national level this is  coordinated through the NFCC and supporting
committees as mentioned previously.

At a local level, Northamptonshire Fire and Rescue Service develop prevention strategies through
analysis of local  risk (Integrated  Risk Management Planning) and through developing delivery
plans through the integrated  Fire/Police community safety function and through our fire station
based personnel who are embedded within the local communities.

One of the key activities undertaken is the undertaking of Home Fire Safety Checks (HFSC) to
residents.  In the past ten years Northamptonshire Fire and Rescue Service has carried out over
50,000 of these visits, this has included the fitting of free smoke detectors In the majority of cases.
Where appropriate, work is carried out in  partnership with other organisations and any potential
risks that are highlighted to us are acted on by our personnel as a matter of priority.

Fire safety advice is regularly delivered to community groups and to residents living in sheltered
accommodation, which cover the dangers of cooking, using candles / prayer shrines, smoking,
electrical appliance, the flammability of Sari's and what action to take if they catch fire.  At these
visits  posters and fire  safety information  are  handed out to display  around the building  and
individuals' flats.

As a Service we also provide safety messages via our website at www.Northantsfire.ora.uk along
with Social Media Facebook and Twitter which provide regular safety messages throughout the
year.

Specific Actions following the Incident on 27 December 2016:

Whenever a serious fire such as this occurs, a Community Impact Assessment is undertaken to
capture all  of the information  required to inform follow-up action  to  help  prevent any similar
occurrences. In respect of this incident we have been working with a number of partners including
the Housing Scheme Managers for Nazarana and Ghirana Nivas, representatives of the building
owners and management, Northamptonshire Police Community Engagement Officers.

During the weeks following the fire, the Service maintained a constant presence in  Nazarana to
support and provide reassurance and advice to the Scheme Manager, family of the deceased and
other residents and their families. A fire safety information poster (attached) was put together by
our Prevention Team and Arson Task Force detailing what to do if  clothing catches fire.  The
poster was translated into Gujrat and Bengali and displayed around the building as well as being
put in Gharan Nivas, Albert Road, Wellingborough, their sister organisation.  Fire Safety booklets,
in Gujrat, Bengali and English were also distributed.  The owners and managers of the premises
(Accord Group) ensured that posters in  both of their properties (Nazarana and Ghirana Nivas)
were distributed to all residents' flats and communal areas.

On 13 February 2017, our District Liaison Officer met with a number of staff from the Accord Group
at Nazarana to discuss how fire  safety awareness amongst the residents could  be improved.
Attendees at the meeting included the Scheme managers for the two sites, the Accord Group Risk
& Health & Safety Manager, the Accord Group Head of Locations and representatives from the
NFRS Prevention Team.

 During the meeting it was decided to do deliver a safety talk to residents from both Nazarana and
Ghirana Nivas sites at the same time. The topics covered at the safety talk to residents were:

•  Site Fire Evacuation Procedure - explained and given out to each resident and displayed in

corridors.

•  Stay Put Policy - explained and given out to each resident and displayed in corridors.
•  Procedure if there is a fire in communal area or corridor.
•  Candle safety - explained and leaflet given to each resident.
•  Converting to battery candles - Accord offered to buy the residents the battery operated

candles if they committed to change to these. All residents agreed to this.

•  Clothing catching fire - explained the stop, drop and roll procedure.
•  Incense sticks / prayer shrines - explained dangers of leaving them burning and carrying

around.

•  Cooking safely - explained oils, unattended cooking and not tackling a fire themselves and

raising the alarm.

•  Electrical safety - explained voltages of appliances that residents may have brought back

from abroad which could be dangerous.

•  All residents agreed to home fire safety checks and crews delivered them. 
 to do monthly checks and remind residents of safety advice.

On 26 April 2017, our District  Liaison  Officers discussed the incident at the East and West
Midlands Prevention Managers meeting to share the learning with colleagues from other brigades.

On 29 June 2017, six months after the incident, home fire safety checks were carried out at
Nazarana, together with the Scheme Manager to ensure residents were continuing to follow the
advice that had been given to them. Although no serious safety issues were identified, concerns of
potential hazards in kitchens were highlighted with wearing traditional Saris.  Additional electrical
points and broken electrical points were highlighted, as some residents were housing fridges and
fridge freezers in their bedrooms which were blocking exits.  Our prevention team were pleased to
report back after their safety checks, that all the residents were using the battery candles.

On 30 June 2017 a joint safety talk to a Hindu / Sikh Women's Community Group was given with
Police Community Engagement Officers also in attendance.

As part of our prevention strategy going fonA/ard we contacted Dostiyo who run a weekly group at
Nazarana.  Joint safety talks from the police and fire are now taking place at these meetings.
 who runs Dostiyo group also oversees the Zingali group which has a group for women and
men each consisting of 30 predominantly retired members from the Hindi and Sikh community and
visits are also planned for them.

We have linked in with The Indian Hindu Welfare Organisation to deliver home fire safety talks and
they have agreed to advertise fire safety messages in their quarterly newsletters. The Independent
Advisory Group for Wellingborough and East Northants has agreed to assist us with engaging with
the Indian community with fire safety education.

Police Community Engagement Officers send out quarterly Safety Newsletters to 900 Community
Leaders across the county which will include fire safety messages.  These leaders have been
invited to attend a meeting at Police and Fire Headquarters at Wootton Hall on 19 October 2017.

 , %

Our prevention team will be In attendance to ensure safety messages reach all communities and
discuss future planned work.

I  do hope that the information within our response to your Regulation 28 Report provides you with
an assurance that NFRS has not only responded appropriately to this very serious fire incident but
that there are suitable and sufficient mechanisms in place at a local and national level to ensure
that risk information is shared effectively and that Northamptonshire Fire and Rescue Service will
continue to feed any learning outcomes into prevention strategies and action plans in order to help
prevent incidents occurring.

Please do not hesitate to contact me if you need anything further.

Darren Dovey
Chief Fire Officer

cc: 

Anne Pember, HM Coroner for the County of Northamptonshire

Enc.  Home Fire Safety Checklist

Poster

Attachments

loose clothing
presentation 2013. pp

httDs://vimeo.com/15841343

https://vimeo.eom/158339943

https://vimeo.eom/19395062

East Sussex Fire and Rescue Service shared the following case study, videos and safety
leaflet:-

http://www.esfrs.orQ/black-museum-cases/all-the-black-museum-cases/vulnerable-people-and-

clothino-fires/

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