Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0172, written 28 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 | 28 Mar 2019 |
|---|---|
| Reference | 2019-0172 |
| Deceased | Tony Goodridge |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell
HM Senior Coroner
Inner North London
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Executive Directors of Supporting Communities
London Borough of Camden
1
CORONER
I am: Assistant Coroner Sarah Bourke
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
2
CORONER’S LEGAL POWERS
I 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 27 November 2018 I commenced an investigation into the death of Tony
Goodridge (aged 55 years). The investigation concluded at the end of the
inquest on 27 March 2019.
The conclusion of the inquest was that: Mr Goodridge died in a fire at his home
on 19 November 2018.
The medical cause of his death was: 1a inhalation of fire fumes and airway
burns
I recorded a short-form conclusion that Mr Goodridge’s death was an accidental
death.
4
CIRCUMSTANCES OF THE DEATH
. The landlord is the London
Mr Goodridge was the tenant of
Borough of Camden. He returned home to his flat around 2 am on 19 November
2018. At about 4 am a neighbour to the rear of the property noted that there
was a fire in a 2nd floor flat on Brassey Road. Firefighters were called to the
scene and identified that the fire was located in Mr Goodridge’s flat. They
forced entry to the flat by removing the front door. Mr Goodridge was found
unresponsive on the floor behind the front door to the flat. He was recovered
from the property and attempts were made to resuscitate him initially by
firefighters, then paramedics and ultimately a doctor from the HEMS service. He
did not recover consciousness. His death was confirmed shortly after 5 am. The
fire was investigated by the London Fire Brigade. It is evident that the fire was
intense and caused extensive damage to the property including a partial
collapse of the roof. The Fire Investigator’s view was that the fire started in Mr
Goodridge’s bedroom. The likeliest cause of the fire related to smoking
materials, incense sticks or an electric heater coming into contact with
combustible materials. There was no smoke alarm in the property. The evidence
from the fire service was that smoke alarms can alert occupiers to the existence
of a fire earlier and therefore possibly improve their prospects of escaping from
a property.
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 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) Mr Goodridge did not have a smoke alarm in his property.
(2) The London Fire Brigade had some difficulty reaching the property due to
parked vehicles in the vicinity.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and your organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 23 May 2019. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:
(daughter)
I 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.
Sarah Bourke
Assistant Coroner
28 March 2019
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