Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0272, written 14 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Aug 2019 |
|---|---|
| Reference | 2019-0272 |
| Deceased | Christopher Hart |
| Coroner | Chris Morris |
| 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 THIS REPORT IS BEING SENT TO: Yvonne Castle, Chief Executive Officer, Johnnie Johnson Housing, Astra House, Spinners Lane, Poynton, Cheshire, SK12 1GA. CORONER lam Chris Morris, Area Coroner for Manchester South. 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation. gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 20" February 2019, an inquest was opened into the death of Christopher Carlton Hart who died on 11" February 2019 at Stepping Hill Hospital, Stockport aged 33 years. The investigation concluded with an inquest which | heard on 1%t August 2019 and which concluded with a conclusion of Accident. CIRCUMSTANCES OF THE DEATH Mr Hart had been a tenant of Johnnie Johnson housing since around 2016. On 13" January 2019, emergency services were called to reports of a fire at his rented flat in Shawcross Fold, Stockport. Mr Hart was found collapsed in the flat by firefighters who extracted him from the building and administered cardio-pulmonary resuscitation. He was taken to Stepping Hill Hospital in Stockport where, despite intensive care and treatment, he died. A senior doctor at the hospital confirmed Mr Hart died as a consequence of complications of injuries sustained in the fire. An investigation undertaken by Greater Manchester Fire and Rescue Service concluded that the likely cause of the fire within Mr Hart's flat was a discarded cigarette igniting some bedding which had been placed on a sofa at the property. 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) The court heard evidence that toxic fumes from furniture such as sofas which do not conform to relevant fire safety standards can quickly incapacitate someone who breathes them in. It is a matter of concern that Johnnie Johnson Housing imposes no conditions on its tenants as to the conformity of items of furniture with relevant fire safety standards; 2) The court also heard evidence that, had a sprinkler system been installed within the flat, the chances of Mr Hart surviving the fire would have been significantly increased. It is a matter of concern that, notwithstanding Mr Hart’s death, Johnnie Johnson Housing is apparently yet to undertake any formal review as to the introduction of sprinklers into all or a proportion of its properties. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 9" October 2019. |, 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 Mr Paul Hart on behalf of Mr Hart’s family. | have also sent a copy to Rt. Hon. Robert Jenrick MP, Secretary of State for Housing, and Louise Atkinson of 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. Dated: 14" August 2019. Signature: Chris Morris HM Area Coroner, Manchester South.
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.
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an a |
HOUSING &
living longer, living better
Mr C Morris
HM Area Coroner — Manchester South
Coroner's Court
1 Mount Tabor Street
Stockport
SK1 3AG
Our Ref: ANS/327
28th February 2020
Dear Mr Morris
RE: Christopher Carlton Hart
Thank you for sharing a copy of the letter you received from Mr Jenrick. His passion for resident safety
is clear and is wetcomed by ourselves at Johnnie Johnson Housing, and the housing sector. His
continued presence in Government will provide some consistency of legislation and future changes to
legislation.
| thought it useful to write back, just to re-iterate that there is no further action for us to take here. Mr
Jenrick’s comments relate firstly to ‘blocks’. Mr Hart lived in a general needs home, built to standard in
1999. There was no high risk identified here to have installed a sprinkler.
His second comment on furniture. For our general needs residents we do not provide furniture, although
we have updated our advisory information on fire safety regulations.
We continue to monitor emerging findings following the Hackitt Review and will continue to update our
approaches as required.
Thank you again for sharing the letter. Please don't hesitate to get back in touch with me if there is any
more information you need.
Yours sincerely
A
HMC. ONER
MANCHES "ER SOUTH
Yvonne Castle
Chief Executive
nni A
Johnnie Johnson Housing AstraHouse | SpinnersLane | Poynton | Cheshire Ski2 1GA.
astral ar 03453055335 —_general.enquiries@yhousing. co.uk
Ons Oum- B= www.jjhousing,co.uk
Johnnie Johnson Housing Trust Limited is a Registered Society (HCA L121) under the Co-operative and Communities.
Benefit Societies Act 2014 and an exempt charity {FCA 191988). VAT Registration No. 570-7182 38.
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