Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0181, written 30 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 May 2019 |
|---|---|
| Reference | 2019-0181 |
| Deceased | Peter Moran |
| Coroner | Margaret Jones |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Community health care · Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANDREW BARKLEY
LL.B, Hon DUniv
HER MAJESTY’S CORONER
for the
Stoke-on-Trent and North Staffordshire
Coroner’s Area
CORONER’S CHAMBERS,
547 HARTSHILL ROAD,
STOKE-ON-TRENT ST4 6HF
Tel: (01782) 234777
Fax: (01782) 232074
Email: coroners@stoke.gov.uk
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
A R 1 Homecare Ltd, 91 St John’s Road, Biddulph, Stoke-on-Trent, ST8 6LL
CORONER
I am Margaret J Jones HM Assistant Coroner for Stoke-on-Trent & North Staffordshire
CORONER’S LEGAL POWERS
1
2
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 30/11/2018 I commenced an investigation into the death of Peter Moran. The investigation
concluded at the end of the inquest 10th May 2019. The conclusion of the inquest was The
deceased was 89 years of age and had a history of chronic obstructive pulmonary disease,
diabetes, irregular heartbeat, dementia and limited mobility. He lived alone and had a care plan
in place. Precautions had been taken to reduce the fire risks in the property. The carers had
been instructed to remove knobs from the cooker after use and place them out of reach of the
deceased. On 8th August 2017 a carer visited the deceased and cooked breakfast. The gas
cooker grill element had not been fully turned off, leaving an almost invisible flame still burning
when the carer left. The cooker knobs and lighter had been placed on top of a cupboard out of
reach of the deceased. Other visitors during the evening did not notice the lighted grill. At
around 3.00am on 9th August 2017 the deceased got out of bed. He noticed the grill was still
ignited and used a taper to take a flame from the grill and attempted to light the gas fire in the
lounge causing the plastic log effect to smoulder. The Fire and Rescue Service attended and
found the deceased inside the property. The grill was alight and the cooker knobs and lighter
were still on top of the cupboard. He was taken to the Royal Stoke University Hospital, Stoke-on-
Trent where he died at 2.30 am on 19th August 2017. The medical evidence was that the cause
of death was hospital acquired respiratory infection due to smoke inhalation with underlying
chronic obstructive pulmonary disease and ischaemic heart disease.
4
5
CIRCUMSTANCES OF THE DEATH
See above.
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. –
(1) There had clearly been instructions given by the family that the deceased was a fire risk and
they had agreed with carers they should switch off appliances and remove the cooker knobs, and
place them out of reach of the deceased. The cooker had not been properly turned off by the
carer before the knobs had been removed.
(2) Removal of knobs did not appear to be an appropriate method of making the appliance safe.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you A R 1 Homecare
Ltd have the power to take such action.
YOUR RESPONSE
7
You are under a duty to respond to this report within 56 days of the date of this report, namely
by Friday 26th July 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:-
1.
2.
3.
(Staffordshire Fire & Rescue).
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.
9
30 May 2019
Signature
Margaret J Jones HM Assistant Coroner Stoke-on-Trent & North Staffordshire
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.
AR1 HOMECARE LTD
ra
G
Citation
ARI HOMECARE ‘APPROVED
Because Ve
ARI Homecare
91 St Johns Road
MC. JIS Biddulph
Stoke On Trent
a
2 TUL aig ST8 6LL
STG {
NORTE Rrareee NO Telephone 01782 518229
20.03.2018
Dear Ms Jones
In response to your report regarding the late Mr Peter Moran I am informing you of the action taken
by ARI Homecare, I am not going to say there is no proposed action as it does not pay to be
complacent, so we carry out regular reviews on each client as it is a continual learning process when
dealing with people.
My concern which I felt had to be introduced was observation and awareness, the fact that no one
throughout the day had picked up on the eye level grill in a small kitchen was on, the kettle is situated
on the worktop right next to the cooker and everyone who had visited that day and made a cup of tea
had not noticed or felt the heat coming from the eye level grill.
I have attached photocopies of our procedures in which we deal with H & Safety in our client’s
homes.
Document |: This is a Generic Risk Assessment we take when we visit any potential clients, the
assessor will go through this, I would like to draw your attention to page 4 where we have added that
under no circumstances do we remove any knobs from appliances, and recommend the request of a
Fire Officer to visit
Document 2: Is a Risk Assessment Analysis / Action we use for electric and any gas appliances
Document 3: Is the training we provide to every member of staff, (a) Is a book on Fire Awareness in
which staff have to read and fill in a questionnaire — This is provided by CQM Learning, (b) Is a DVD
which explains the reason and causes of fires and how easily it can happen- This is provided by
Mulberry House.
Document 4: Is an example Risk Assessment which we use for staff induction/ training in which we
highlight areas of concern (see page 4)
ARI Homecare have also signed up with a Company called Atlas/ Citation who offer Risk
Assessments, online Fire Training and 24/7 advise on all aspects of Health & Safety. (Document 5)
Company Registered and Postal Address:
AR1 Homecare, 91 St Johns Road, Biddulph, Stoke on Trent, ST8 6LL. Tele: 01782 518229
Company Reg No.: 8569315
COC Registration 04/08/2013
It is important to us that we carry out regular reviews on each client and staff are fully aware of
procedures and empowering them to be aware of any risks within their working environment.
Once again, | reiterate that you cannot be complacent but please be assured that we will continue to
take all the necessary measures to increase awareness in the safety of our clients.
Kind Regards
VMlemeey
Irene Merricks
Director
ARI Homecare
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