Prevention of Future Deaths reports · 2020
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 report | 17 Nov 2020 |
|---|---|
| Reference | 2020-0237 |
| Deceased | Neil Barre |
| 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: 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
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.
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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