Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0236, written 17 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2020 |
|---|---|
| Reference | 2020-0236 |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (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.
Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 17.11. 2020 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Team Leader Si Copy to: Housing of Vulnerable People -Remediation Policy and Delivery (Building Safety) CORONER | am Mr Andrew A Haigh HM Senior Coroner for Staffordshire (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://Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 13 February 2019 | commenced an investigation into the deaths of Riley John HOLT, Keegan Jonathan UNITT, Tilly-Rose UNITT, and Olly UNITT. The investigation concluded at the end of the inquest on 12 November 2020. The conclusion of the inquest was ‘fumes from fire caused by unextinguished cigarette’ with the death having resulted from ‘Inhalation of products of combustion’ CIRCUMSTANCES OF THE DEATH: The four children died in a fire at their home in Stafford in the early hours of 5th February 2019. They had been asleep in their beds when the fire was started by a lit cigarette igniting bedding in their parents’ bedroom. CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter 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 MATTER OF CONCERN is as follows: During the course of the evidence about these sad deaths it was reported that 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk children under the age of 16 (and particularly boys) do not respond to conventional smoke alarms. This adds to the argument that in England ( to copy what is already legally required in Wales) all new built properties should be required to have a fire suppression system installed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 12.1.2021. |, 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 the following Interested Persons: Family | have also sent it to other interested persons 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 : 17.11.2020 Signature wt A Hay Andrew Haigh Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk
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.
eB Ministry of Housing, Communities & Local Government Andrew Haigh HM Coroner for Staffordshire South 1 Staffordshire Place Stafford Staffordshire ST16 2LP Rt Hon Robert Jenrick MP Secretary of State for Housing, Communities and Local Government Ministry of Housing, Communities and Local Government Fry Building 2 Marsham Street London SW1P 4DF Tel: Emait: www.gov.uk/mhclg Our re Your ref: 4 ft December 2020 Thank you for your report dated 17 November under regulations 8 and 29 of the Coroners (Investigations) Regulations 2013. | was very sorry to read of the tragic deaths of Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt in Stafford on 5‘ February 2019. Any accidental death is upsetting, but the untimely deaths of four children is unbearable. The Government are committed to bringing about the biggest change in building safety for a generation. Part of that programme of work is a full technical review of the standards that support building regulations the important issues of smoke alarms and sprinklers will, of course, be considered as part of that review. | understand that the specific issue of smoke alarms waking children was considered by the relevant technical committee at the British Standards Institute and that this was taken into account in an amendment to BS 5839-6 issued this year. Teck recele. _—_—— RT HON ROBERT JENRICK MP
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