Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0274, written 15 Aug 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 Aug 2017 |
|---|---|
| Reference | 2017-0274 |
| Deceased | Ian Leak |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Bronwen Rapley, Chief Executive, Peak Valley | Housing Association, The Hub, Stockport Road, Mottram, Hyde SK14 6AF. CORONER lam, Chris Morris, Area Coroner, for the coroner area of South Manchester 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 INVESTIGATION and INQUEST On 25" April 2017, Alison Mutch OBE, Senior Coroner for Manchester South, commenced an investigation into the death of lan Leak who was aged 59 when he died at his home address on 5" March 2017.The investigation concluded on the 10" August 2017. The conclusion of the inquest was that Mr Leak died as a consequence of a fire in his flat, which was likely to have been started by a lit cigarette coming into contact with combustible material. At the end of the inquest, | recorded a conclusion of Accident . The medical cause of death was 1a) Fire Related Death fl) Ischaemic Heart Disease. CIRCUMSTANCES OF THE DEATH Mr Leak had suffered from very poor health for a number of years. Having been diagnosed with a brain tumour, he endured some 15 brain operations, and experienced a number of strokes. As a result, Mr Leak was left with significant disabilities. He had serious mobility problems, and his memory was affected. He could also become confused. Mr Leak was a tenant at Peak Housing's Honiton Oaks property, where he had his own flat. On Sth March 2017, the fire service was alerted to a fire at Mr Leak's flat. The flat was entered and Mr Leak was tragically found to have died. '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. - | | heard evidence that Honiton Oaks was, at all material times, equipped with two fire alarm systems, both of which appear to have operated as intended in this case. The first fire alarm system detects heat and / or smoke in communal areas and, if triggered, opens glass smoke vents and deactivates the lift having returned it to the ground floor. In accordance with the ‘Stay Put’ policy currently in operation of Honiton Oaks, whilst this system creates a visual alert on a fire control panel within the building, it does not trigger an audible fire alarm which other residents can hear. The second system consists of combined heat and smoke detectors fitted in tenants’ individual flats. These generate an audible warning within the individual flat where the detectors have been triggered, but operates independently of the system covering the communal areas. In the course of the inquest, | heard that as a result of planned upgrades to the Honiton Oaks alarm systems, from the end of this month, the communal system will be linked to an external monitoring service in addition to the internal panel. | also heard evidence to the effect that Mr Leak was not the only tenant with mobility problems who resided at Honiton Oaks. In such circumstance, the matter of concern is that in the light of the building’s ‘Stay Put’ policy, consideration should be given in the case of tenants who have particular mobility problems or are otherwise likely to have difficulty in escaping from a fire within the confines of their own flat, to arranging for external monitoring of the individual fire alert systems within those tenants’ flats. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10" October 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) EN partner of the deceased. sister of the deceased, who may find it useful or of interest. | have also sent it to Greater Manchester Fire and Rescue Service who may find it useful or of interest. | 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. Christopher Morris. Area Coroner Manchester South ) 15/08/2017 nN
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.
HTP.PV.05 17
The Hub
Stockport Road
Mottram
Hi
b S
yde
SK14 GAF
Pea k Va | | e Te! 0345 270 3501
Fax. 0161 882 9840
HOUSING ASSOCIATION:
www pvha co uk
=e Email: mail@pvha co uk
Mr Christopher Morris
Area Coroner
Coroners Court
1 Mount Tabor Street
Stockport
SK1 3AG
By Post & Email
5" October 2017
Dear Mr Morris,
Regulation 28 Report — 6820/CH
Thank you for your Regulation 28 Report dated 15" August 2017, which outlined the
tragic circumstances of this incident. The safety of our customers is our highest
priority and we operate clear fire safety procedures to ensure we comply with current
legislation and keep our customers safe.
Honiton Oaks is a relatively new building, constructed in accordance with building
regulations and following receipt of your report we have met with the local fire
authority to explore and review a range of potential options.
We understand the concerns raised in your report relate to the ability of some
residents to raise the alarm in the event of a fire incident, where a ‘stay put’ policy
operates.
| can advise that we agree with your recommendations and are proposing to
undertake the following actions as a result of this case.
We have been working with specialists and have approved the design for
improvements to the existing fire alarm systems within Honiton Oaks. The design
includes the installation of combined heat and smoke detectors to residents’ flats,
linked to the main system, which will provide early warning to all residents within
Honiton Oaks. The system will operate with external monitoring and the work is
programmed to commence during October 2017.
As a result of the tragic fire at Grenfell, we have also commenced a wider review of
fire safety across the Onward Homes portfolio. As part of this review we will look
specifically at our approach to vulnerable residents to ensure we minimise potential
risks. We are aware a national review of building regulations has commenced, which
includes fire safety and we continue to monitor developments.
Registared Ollica The Hub. Stockport Road, Mottram. Hyde SK14 6AF gt hlay, .
Paak Vailay Hous:ng Association is ragistared with the Homes and Communities Agency (No 14475 ) 3 6/6, ‘¢
Peak Valley Housing Association is a registered society under the Co-operative and Community Benetit Societies Act 2014 (No 29311F)} L A
Past of Onward Homes Bart
HIP.PV.05 17
The Hub
~ Stockport Road
a7 Mottram
Hyde
SK14 6AF
Peak Valle Tel: 0345 270 3501
Fax 0161 882 9B40
HOUSING ASSOCIATION
www pvha.co uk
Email mait@pvha co uk.
If you require any additional information please do not hesitate to contact me.
Yours sincerely
}
fl
Bronwen Rapley
Chief Executive Officer
:
Registered Ottice The Hub. Stockport Road Motuam, Hyde SK14 BAF
Peak Valley Housing Association Is registered with the Homes and Communities Agency {No L4475 )
Poak Valiey Housing Association is a registered society under the Co-operative and Community Benatit Societies Act 2014 (No 293118)
Part of Onward Homes
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