Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0257, written 26 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 | 26 Nov 2020 |
|---|---|
| Reference | 2020-0257 |
| Deceased | John Jennings |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Emergency Services related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
John Joseph Jennings (died 18/010/20)
THIS REPORT IS BEING SENT TO:
Ministry for Housing and Local Government
2 Marsham Street,
Westminster
London SW1P 4DF
1
CORONER
I am: H.M. Coroner and Senior Coroner Mr Andrew Walker
Senior Coroner for North
London
Barnet Coroner’s Court
29 Wood Street,
London EN5 4BE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 21st October 2019 I commenced an investigation into the death of John
Joseph Jennings. The investigation concluded at the end of the inquest
held on the 24th November 2020.
The conclusion of the inquest was a short narrative conclusion;
Consequences of a fire at home.
4
CIRCUMSTANCES OF THE DEATH
On the Eighteenth of October 2019 at 01.04 hrs a line was opened to Mr
Jennings from an alarm monitoring company to his home following the
activation of a smoke alarm.
This call did not result in the London Fire Brigade being called until 01.21
hrs . The Code of Practice for Remote Centres Receiving Signals from
Alarm Signals British Standard Code of Practice, if followed, would have
resulted in a call to the London Fire Brigade being made after 90
seconds from the line being opened which would, in this case, have
resulted in the Fire Brigade arriving whist Mr Jennings was still
connected. Had the installation complied with British Standard 5839 at
LD1 Maximum Protection level there would have been more measures
taken to protect Mr Jennings who had only a single fire detector in the hall
at his home. Mr Jennings died at his home from smoke inhalation before
the Fire Brigade arrived.
5
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. Evidence was heard expressing concern that the above Code of
Practice and British Standard 5839 LD1 Maximum Protection level were
not currently statutory requirements.
6 ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I believe
that your organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of
this report, namely by 20th January 2021 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 following.
● The Family,
● The Deputy Assistant Commissioner London Fire Brigade
● London Borough of Barnet
● Medvivo Group Ltd
● Telecare Services Association
● National Fire Chiefs Council
● All London Local Authorities
● Care Quality Commission
● British Standards Institute
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
26th November 2020. H M Coroner and Senior Coroner
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.
a Rt Hon Robert Jenrick MP a . Secretary of State for Housing, Communities and Local Ministry of Housing, Government Communities & Local Government Ministry of Housing, Communities and Local Government Fry Building 2 Marsham Street London SW1P 4DF Mr Andrew Walker North London Coroner's Service, Barnet, Brent, Enfield, Haringey and Harrow, Barnet Coroner's Court 29 Wood Street www.gov.uk/mhclg Barnet ; ENS 4BE Our Ref m7 Dear Aydsew _D } Thank you for your report dated 17 November under regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. /2* January 2021 | was very sorry to read of the tragic death of Mr John Joseph Jennings 20th October 2020. Your report states that Mr Jennings died as a result of a fire in his home and that there were delays in calling the fire and rescue service via an alarm monitoring company. You have raised a concern that the statutory minimum provision of smoke alarms is less than the maximum offered in British Standard 5839. The current guidance supporting building regulations currently sets the minimum level of protection at LD3 in new homes. When this matter was last reviewed, it was concluded that LD3 was an appropriate standard for the general population, however it is recognised in the guidance that a higher standard may be justified where the residents of a building are more vulnerable. It is not clear from your report why it was considered necessary to provide Mr Jennings with a connection to an alarm monitoring company. If this was as a result of him being identified as vulnerable, then one might ask why the level of fire detection was not also considered at that time. | have asked my officials to raise this with the relevant committee at the British Standards Institute for consideration. 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 will, of course, be considered as part of that review. Thank you again for your letter. a RT HON ROBERT JENRICK MP
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