Prevention of Future Deaths reports · 2020

Neil Barre

Regulation 28 report to prevent future deaths, reference 2020-0237, 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 report17 Nov 2020
Reference2020-0237
DeceasedNeil Barre
CoronerAndrew Haigh
Coroner areaStaffordshire (South)
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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:
Staffordshire Fire and Rescue Service HQ
Pirehill Stone Staffordshire ST15 OBS

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:/Avww. 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 16 September 20201 commenced an investigation into the death of Neil BARRE. The
investigation concluded at the end of the inquest on 12 November 2020. The conclusion of
the inquest was ‘Accident’ with the death having resulted from burns sustained during a
house fire.

CIRCUMSTANCES OF THE DEATH:

Mr Barre died at the Queen Elizabeth Hospital in Birmingham on 11th September 2020
from burns sustained in a fire at his home in Cannock. Earlier that day he had dropped
a cigarette while smoking in bed despite having been warned about the dangers of
this activity.

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 inquest a suggestion was made that it may be helpful for
Staffordshire Fire and Rescue Service to be aware of when those receiving domiciliary

1 Staffordshire Place, Stafford, ST16 2LP
Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk

care are not using special equipment (such as fire retardant blankets) that are
provided to them. Staffordshire FARS may well have links with groups providing care
and there could be greater use of communications with such groups.

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

Care Quality Commission

West Midlands Fire Service

| 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

wth 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

Responses

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.

Response from Staffordshire Fire and Rescue Service (PDF)
Mr A. Haigh 
Senior Coroner Staffordshire South 
Coroner’s Office 
1 Staffordshire Place 
Stafford ST16 2LP 

Dear Mr Haigh 

Please reply to:  

Staffordshire Fire and Rescue Service,  
Headquarters  
Pirehill, Stone  
Staffordshire  ST15 0BS  

Telephone: 
Email:  

Date: 8th Feburary 2021 

Regulation 28 Report – Neil-Barre-2020-0237, Sylvia-Griffiths-2020-0238 

In response to your letter received on the 17th November 2021 outlining your findings following the 
inquest in to the death of Neil Barre, and the inquest into the death of Sylvia Griffiths, I would like to 
provide an overview of the work Staffordshire Fire and Rescue Service is undertaking in response to 
your concerns raised in the Regulation 28 reports. 

Staffordshire Fire and Rescue Service will be conducting a fatal fire review of the case. This will 
involve your findings from the Coroner’s inquest along with a review of partnership and prevention 
activity the fire and rescue service conducts in cases such as this. 

The fatal fire review will involve Staffordshire Fire and Rescue Service along with key partner 
agencies and will aim to capture any multi agency learning from this tragic event. Following which 
the identified learning will be used to review our prevention and partnership activity in order to 
ensure the potential for further deaths of this nature are prevented. 

The learning will also be shared with other fire and rescue services nationally through our national 
prevent networks also aimed at raising awareness of cases such as this and to share best practice to 
ensure prevention activity meet the needs of our communities. 

Due to current COVID 19 restrictions the fatal fire review will be taking place virtually W/C 22 
February 2021 all actions and learning will be recorded. Staffordshire Fire and Rescue Service will 
ensure a record of the learning is shared through the Coroner’s office for your awareness by the 1st 
March 2021. It is proposed the learning will also be shared with local partner agencies along with fire 
and rescue services nationally on the above date. 

Due to the tragic nature of these events we are keen as a service to ensure we take every step in 
preventing future fire deaths by working closely with partner agencies and consistently reviewing our 
approach to prevention activities. By doing this we try to ensure our most vulnerable members of the 

 Chief Fire Officer 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 
 community are identified and protected at the earliest opportunity using equipment and technology 
available providing a safer environment to live.  

Additionally – Staffordshire Fire and Rescue Service run a scheme called ‘Olive Branch’. This scheme 
provides training to people who are in contact with, or visit vulnerable members of communities 
within Staffordshire and Stoke-on-Trent. It encourages them to identify potential fire hazards and 
other risks in the home. In addition it highlights how to refer vulnerable people onto Staffordshire 
Fire and Rescue Service for Safe and Well advice. 

Olive Branch was launched in February 2011 after a report by the coroner investigating the death of 
, and has since been adopted by other local authorities and Fire Services.  The primary 
aim of the Olive Branch Programme is to reduce the number of accidental dwelling fires, fire-related 
deaths and injuries across Staffordshire & Stoke-on-Trent. 

The training is free and we will deliver to groups of any number at either their premises or at venues 
supplied by us across Staffordshire and Stoke-on-Trent. We aim to train all persons involved with 
caring for the elderly, disabled and vulnerable on a daily basis in how to identify hazards and to 
understand how to deal with these risks and to refer them on to the appropriate organisation. Each 
session lasts minimum of 1.5 hours and each delegate receives a certificate of attendance. 

Staffordshire Fire and Rescue Service work closely with partner agencies and Olive Branch training 
has recently been redeveloped to accommodate our ever changing community needs. The findings 
from the investigation into the death of Sylvia Griffiths and Neil Barre will be fed into these training 
sessions, particularly the availability and use of fire/smoke alarms that are designed for people 
suffering with dementia. These training sessions will also be used to improve communication with 
groups who provide domiciliary and reinforce feedback regarding people who may not be using the 
special equipment provided to them.     

Thank you for raising your concerns and providing us with the findings from your inquest, as a sector 
we will make every effort to learn from this tragic event in order to prevent further potential deaths 
and injuries. 

Yours sincerely 

Howard Watts 
Director of Prevent & Protect

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