Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0110, written 22 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Mar 2019 |
|---|---|
| Reference | 2019-0110 |
| Deceased | Bram Radcliffe |
| Coroner | Martin Fleming |
| Coroner area | West Yorjshire (West) |
| Category | Product 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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT IN THE MATTER OF: The Inquests Touching the Death of Bram Luke Radcliffe A Regulation Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: Jane Buxey — Chief Executive — Stone Federation of GB Bs HIM Principal Inspector SENET BSI Brian Martin - Ministry of Housing, Communities and Local Government CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the coroners and Justice Act 2009 and regulations 28 and 20 of the Coroners (Investigations) Regulations 2013 3 | INVESTIGATION and INQUEST On 24/11/17 I opened an inquest into the death of Bram Luke Radcliffe who, at the date of his death was aged 2 years old. The inquest was resumed and concluded on 15/2/19 I found that the cause of death to be: - la. Head Injury I arrived at a narrative conclusion as follows: On 8 November 2017 Bram Luke Radcliffe was found unresponsive with a serious head wound in the living room of his home address at West Yorkshire, after he was struck by a fire surround which had become detached from the wall. When taken to hospital, notwithstanding treatment, he succumbed and. died later the same day from his injuries. Although the person or persons responsible for fitting the fire surround cannot be traced, it is found more likely than not that its installation was substandard and dangerous. LL RT3589 1 4 | CIRCUMSTANCES OF THE DEATH On the morning of 8/11/17, during a very brief moment upstairs Bram’s mother was alerted by a loud crash coming from the downstairs living room. Upon re-entering the living room she found Bram unresponsive on the living room floor surrounded by the marble fireplace which had become detached from the wall. Upon the arrival of the ambulance urgent CPR was carried out and he was rushed to hospital, but it was there given the extent of his head injury he succumbed and passed away, later the same morning. CORONER’S CONCERNS During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/suppler and good building practice. The MATTER OF CONCERN is as follows: - e To review the existing BSI 1251 ‘Open-replace Component’s, which deals with the manufacture of the components and to consider whether it is appropriate to extend it to the installation of the components. e Since the key issue relates to the quality and reliability of workmanship linked to the installation of stone fireplace surrounds, consider the appropriateness of reviewing existing regulations and codes of practice to ensure compliance and guidance and suitable measures in order to prevent further similar incidents occurring. , e Consider whether provision of a fire surround should be regarded as ‘building work’ such that it be subject to the building regulations. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the CE to the Stone Federation, HM Principal Inspector, BSI and Ministry of Housing Communities and Local Government have the power to take such action specific to them. In the circumstances it is my statutory duty to report to you. RT3589 2 7 | YOUR RESPONSE . You are under a duty to respond to this report within 56 days of its date, I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 | COPIES Ihave sent a copy of this report to: - Mother Father BEES Diagencsis METAS Royal Institution for Chartered Surveyors Chief Coroner DATED this 22/3/19 Senior Coroner Vier, RT3589 3
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