Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0362, written 3 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Oct 2018 |
|---|---|
| Reference | 2018-0362 |
| Deceased | Canon Frost |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Head of the Roman Catholic Church of England and Wales The Diocese of Westminster Vaughan House 46 Francis Street London SW1P 1QN And East Coast Community Healthcare Team Patrick Stead Hospital Bungay Road Halesworth IP19 88SG 1 | CORONER lam Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 2 | 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. 3. | INVESTIGATION and INQUEST On ist August 2016 | commenced an investigation into the death of Brian Alban Frost The investigation concluded at the end of the inquest on 10! Sept 2018. The conclusion of the inquest was that the death was an accident. The medical cause of death was confirmed as: 4(a) Head and neck injuries following a fall 2. Marginal zone lymphoma and ischaemic heart disease. 4 | CIRCUMSTANCES OF THE DEATH On the 30! June 2018 Canon Frost had an unwitnessed fall in his home at [iE during which he sustained severe head injuries. He was found by his next-door neighbours who called the emergency services. Canon Frost was pronounced dead at the scene at 19.52 hours by a member of the East of England Ambulance Service. The Suffolk Constabulary conducted enquiries and concluded there was no third-party involvement in Canon Frost's death. Canon Frost was taken to the James Paget Hospital in Gorleston, Norfolk where conducted a post-mortem examination on the 4” July 2018 providing the cause of death as; 1(a) Head and neck injuries following a fall and 2, marginal zone lymphoma and ischaemic heart disease. Canon Frost was a 92yr old retired Roman Catholic priest who lived alone but had a goad relationship with his neighbours. Canon Frost's neighbours attended at approximately 1100hrs the moming of 30% June 2018 and found Canon Frost in the rear garden. They went round as they heard strange noises coming from his garden and they shouted to ask if he was ok. Canon Frost replied that he wasn't, therefore they went to help him. He was found on top of a planter and couldn't get himself up. They stayed with him for approximately 30mins. Canon Frost stated he had a fall and said he had a nose bleed. He also had what is described as a graze on the top of his head and a small cut to his arm. He refused ambulance or medical assistance but was assisted by his neighbours. The neighbours left Canon Frost's address and returned in the evening. Canon Frost's front door was unlocked as he tended to leave it during the day (normally only locking it in the evening). The neighbour entered the property as she had some fresh vegetables to give him and found him in the kitchen on his front, unresponsive with a large pool of blood underneath him. ‘The rear door of the property was open but there is no disturbance seen in the property, with money still remaining on his dining room table. The hob of his oven was switched on and Canon Frost was found with a slice of bread by his left-hand side. Canon Frost was found with a large laceration to his forehead, graze to his right knee and various bruising to different parts of both arms. Canon Frost is described by his neighbours as regularly having falls and being unsteady on his feet. Canon Frost had a bad fail in summer of 2017 and was admitted to James Paget Hospital after fracturing his hip and had had a number of subsequent falls since. Canon frost's home was not his own but is owned by the Roman Catholic Diocese of Northampton 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 as follows. — 1. There is a clearly identifiable history that Canon Frost had become prone to falls and was unsteady on his feet. 2. Photographic evidence produced during the inquest of Canon Frost clearly demonstrates that the floor tiles in his kitchen had become loose and were no tonger fastened to the floor. One of the floor tiles is completely out of position and the others appear to be loose with large gaps between the tiles themselves. in his witness <toton cr TTT :ommented “the flooring where Canon Frost would have fallen was very loose and could have been a trip hazard for Canon Frost.” 3. Considering his frailty, the fact he lived alone and the medical conditions suffered by Ganon Frost, on the available evidence this flooring was clearly not safe by any measure. In evidence it was heard that the flooring is sufficiently poor that it will need to be replaced prior to the re-occupation/sale of the property. 4. Evidence heard that the Bishop of each diocese is responsible under ‘canon law’ for accommodating retired priests of the diocese. This is generally done on a ‘grace and favour’ tenancy of a diocesan owned property. There is no legal agreement for the occupation, but the general understanding is that the diocese provides the property and the retired priest is responsible for paying for all the service and maintaining the property. The retired priest receives an annual payment to cover the costs of services charges and general maintenance. It was heard that this is common practice in the 22 Roman Catholic dioceses of England and Wales. 5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost's home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. Anote from the October 2017 visit (11 months prior to Canon Frost's death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost's mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 40. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's home. 44. Given that this is the case | am concerned that other residents of ‘grace and favour homes provided by the Bishop of each dioceses, may now also be living in premises that may no longer be considered safe for their occupation. 12. During the hearing a submission was made by the lawyer representing the diocese involved that as the Local Community Health Team had also visited the property they should be included in this notice to which | agreed. A member of the Local Community Health Team visited Canon Frost on one occasion (10! November 2017) who may have seen the condition of the flooring, and if so may have been in a position to report it. However, as the owner of the home the primary responsibility for ensuring it is safe for occupation, in my opinion falls to the Roman Catholic Church. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 28! November 2018. I, the Senior Coroner, may extend the period if! consider it reasonable to do so. 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. | am 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. a 3" October 2018 Nv. of Nigel Parsley
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.
SVB TVUM PRAGSIOIUN Bishop's House Marriott Street Northampton NN2 6AW Telephone: 01604 715635 Fax: 0 FAO HM Senior Coroner For Suffolk Nigel Parsley Dear Sir, RE: Inquest Touching Upon the Death of Canon Frost We write in relation to the report you made at Ipswich Coroner’s Court under Rule 28 of The Coroners (Investigations) Regulations 2013 following the inquest into the death of Canon Brian Frost on 10 September 2018. We are sorry for any delay in providing this response and are grateful for the extensions that you have kindly provided. May we say at the outset that this response to your Rule 28 report to prevent future deaths is being provided by and on behalf of the Northampton Diocese and not Cardinal Vincent Nichols, one of the parties to whom the report was directed. While we are aware that you directed your regulation 28 report to Cardinal Vincent Nichols, we respectfully suggest that the appropriate party to respond is the Diocese of Northampton and not Cardinal Nichols. We say that for the following reasons. The concerns you expressed relate to the way in which an individual diocese - here the Diocese of Northampton - conducted itself in relation to the well-being of retired priests occupying grace and favour properties. As was explained at the Inquest, these types of arrangements are made on a diocese by diocese basis and no overarching policy of wider applicability exists. The fact that there is no such overarching policy is an inevitable consequence of the way in which the Catholic Church in England and Wales is constituted: each diocese has and maintains its own individual arrangements, While the Archbishop of Westminster (Cardinal Nichols) is, as a matter of custom, elected President of the Catholic Bishops’ Conference of England and Wales, and so is the de facto spokesman for the Catholic Church in England and Wales, he heads the Diocese of Westminster only. This is a distinct and separate diocese from the Diocese of Northampton. It has its own approach towards the provision of grace and favour The Northampton Roman Catholic Diocesan Trust Registered Charity Number 234091 properties and welfare care for retired priests. There has been no suggestion that the way in which the Diocese of Westminster discharged its function was lacking. The Bishop of Northampton is Bishop Peter Doyle, who was ordained as the twelfth Bishop of Northampton on Tuesday 28th June 2005 and is the spiritual head of the Diocese. The Diocese also operates by and through a number of separate departments that include: ; Administrative and Consultative Clergy and Vocations Diocesan Tribunal Ecumenism Education and Schools Finance and Property Human Resources Liturgy Commission Pastoral Ministry Office Pastoral Services While individual dioceses inevitably operate in a similar manner, their manner of operation is not identical, and all have discretion in relation to the way in which they attend to (for example) the welfare of retired priests. Of course, all dioceses are subject to canon law, but canon law is not prescriptive about the way in which arrangements such as the provision of maintenance and residence are devised and implemented. We hope this is satisfactory and explains why this response is provided by the Diocese of Northampton and not Cardinal Nichols. Having said this, Cardinal Nichols is interested and concerned about these matters, and our response to you will be shared with him. We will also endeavour to share the concerns that have arisen from this case, and our response to them, across the other dioceses in England and Wales. By doing this, we hope that all necessary lessons may be learned by those to whom they are applicable. As regards the circumstances of this sad case. As you know Canon Brian Frost was ordained in 1950, served at St Joseph’s Bedford, the Cathedral, Leighton Buzzard, St Joseph’s Luton for 14 years, Rushden for 11 years, then Kettering for three years before a brief spell at St Patrick's Corby, from where he retired in 1995. ired clergyman he was provided with a grace and favour property at ill. you will appreciate, members of the clergy are not employees and therefore the Diocese did not owe a duty under section 2(1) of the Health and Safety at Work ete Act 1974 (‘HSWA 1974’), Even if any such duty is considered to have been owed, it is highly unlikely that it would have extended to his personal residence, where no work activities took place. Of course, the Diocese accepts that it also has wider duties under (principally) section 3(1) HSWA 1974, which is the duty to ensure that non-employees are not exposed to risks to their health and safety arising from the conduct of an undertaking. The Diocese takes the view that the nature of its undertaking in connection with Canon Frost was limited - indeed, there is a strong argument for saying it was exercising no legal undertaking in relation to Canon Frost. Notwithstanding this, we will approach the matter on the basis that it was operating a limited undertaking, which we suggest was no more than that of private landlord or de facto landlord. We say de facto landlord because no formal tenancy or licence was entered into as the property was provided on a grace and favour basis, but the Diocese accepts it was required to discharge the basic statutory functions of a private landlord. These were principally the safe installation and maintenance of gas and electrical equipment; it did this. The Northampton Roman Catholic Diocesan Trust Registered Charity Number 234091 Consistent with canon law and convention, the Diocese provided Canon Frost with a grace and favour residence for his natural life. It was not acting or purporting to act as a Care Home, Retirement Home or other supported living provider. This was not its undertaking or function, nor did it have an obligation under canon law or other provision to exercise this undertaking or function. As a landlord (or de facto landlord) it had few other legal obligations, whether through the English law of real property or canon law in relation to the interior condition of the property. In particular, the Diocese does not accept it was in breach of any repairing obligations it may have had, certainly in the absence of any specific indication that there was a problem with the floor tiles. It also had no other legal obligations in relation to the welfare of Canon Frost merely because he was a retired priest of the Diocese. While it did ensure that a yearly pastoral visit was made to him, it was not thereby assumi lay to day responsibility to safeguard his welfare while resident a iis. you know certain other financial provision was made but this did not bring with it an obligation to ensure, for example, that nothing about the internal fabric of the house presented a day to day risk. Its duties towards securing the welfare of Canon Frost were in fact no more extensive and probably less extensive than those of the social services. We are aware that you have included the Local Authority in your Rule 28 report. ; As was noted at the inquest, the Local Authority was fully aware of Canon Frost’s health issues following his admission into the James Paget Hospital for the cataract operation and undertook a home assessment, finding he was not yet in need of carers. We are conscious of the fact that in asserting what the Diocese says were its legal obligations, it may appear harsh or in some way lacking in compassion. This is not the case: the Diocese always seeks to act with care and compassion to all acting or retired clergy and has regard for their pastoral care. In assessing whether the Diocese did all it ought reasonably to have done in relation to Canon Frost’s welfare, the Coroner is aware that the property at was originally Canon Frost’s sister’s house and he was known to have strong family support in the area. While it is accepted that Canon Frost was becoming frailer and less capable of caring for himself, the Diocese was entitled to think that any issues affecting the safety of his accommodation would have been raised by Canon Frost’s family, if not by Canon Frost himself. If issues about his accommodation had been raised, there is no doubt the Diocese would have ‘addressed them. This would have been done by the Property and Finance Department or Northampton Priest’s fund, which is a separate fund. No such issue was ever raised, either by Canon Frost or by his family. The only request received from Canon Frost was in relation to payment for a cataract operation which was paid for from the Priest’s fund. Having said all of this, the Diocese acknowledges that a state of affairs arose in connection with the property at EE that was unsatisfactory, and it will take all practicable steps to ensure that lessons are learned, and similar events do not occur in the future. The Diocese has already taken steps to ensure that these events do not reoccur, as follows: ¢ The Diocese has reviewed its procedures for supporting retired Priests living in Diocesan accommodation; ¢ All Priests will continue to receive at least annual visits from the Diocesan Clergy Welfare Officer, but the Welfare Officer will be joined on those visits by one of the Diocesan Surveyors; The Northampton Roman Catholic Diocesan Trust Registered Charity Number 234091 ¢ The Surveyor will carry outa full external and internal assessment of the property's fabric and condition, together with a Health and Safety Assessment informed by the advice of the Welfare Officer about the health and mobility of the Priest; * At the end of the survey the Surveyor, the Welfare Officer and the Priest will discuss the findings of the survey. Any repair works noted as being needed or recommended froma property or health and safety perspective will be agreed with the Priest and organised by the Surveyor, who will agree with the Priest suitable times for access and will manage and approve the works. The costs will be borne by the Diocese; * Should the survey identify works that might assist a Priest in his occupation of the property (handrails, grab rails etc), the Surveyor and Welfare Officer will strongly recommend to the Priest that these are carried out and, if he agrees, the Surveyor will organise these as detailed above; * If the Priest does not agree to the recommended works then the Welfare Officer will escalate the issue to the Vicar General or Bishop to agree the next steps; and e Atthe end of every visit the Priest will be left cards showing office hours and out of office hours for both the Welfare Officer and Surveyor in the event that property repairs become needed. We hope that all of this is satisfactory and addresses the concerns that prompted you to issue a Rule 28 Report. Yours faithfully . Director of Finance and Development Diocese of Northampton The Northampton Roman Catholic Diocesan Trust Registered Charity Number 234091
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