Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0293, written 21 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2020 |
|---|---|
| Reference | 2020-0293 |
| Deceased | Brian Easey |
| Coroner | Bridget Dolan |
| Coroner area | West Sussex |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This from is to be used before an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive, , Lambeth Borough Council, Lambeth Town Hall, Brixton Hill, SW2 1RW 2 Chief Executive, , West Sussex County Council, County Hall, Chichester, West Sussex 1 CORONER I am Bridget Dolan, Assistant Coroner, for the coroner area of West Sussex. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION On 16 December 2020 I commenced an investigation into the death of Brian James EASEY aged 79. The investigation has not yet concluded and the inquest has not been heard. 4 CIRCUMSTANCES OF THE DEATH Mr Easey was diagnosed with mesothelioma in September 2020. He provided a witness statement dated 21.10.20 setting out an account of his work exposure to asbestos as follows: In 1965 Mr Easey began working as a registrar for the London Borough of Lambeth and later became a deputy superintendent. He worked there for 19 years. Mr Easey believed that he was exposed to asbestos whilst working at 340 Brixton Road, on a daily basis he would frequently have to enter a fire-proof, strong-room repository room that is believed to have been clad with asbestos. The room was very dusty and the registers would be covered with layers of dust. He stated he often picked them up and used his arm to remove the dust or blew on it to disperse it. There was no ventilation was in the room. Mr Easey later started working for West Sussex County Council (WSCC) in 1984 as a superintendent registrar. For the first 16 years working for WSCC he was based at 15 Mill Road, Worthing. Mr Easey stated that he was exposed to asbestos in the fireproof repository, as the door contained asbestos and the walls were made from asbestos insulation boards. Mr Easey stated that he would enter the room frequently on a daily basis. Mr Easey would brush away the dust with his sleeve causing the dust to be released into the air around him. Mr Easey would often search for records and be leaning against the walls which would leave dust marks on his clothes. Mr Easey has stated that in around 2006 WSCC decided to relocate to Centenary House in Worthing and due to this Mr Easey spent a lot of time in the room moving records and preparing them for transportation. He described it as an extremely dusty process. He undertook this work alone and would be covered in dust by the end of his day. The records relocated to Centenary House were located in a larger modern strong room. In August 2020 Mr Easey began feeling breathless and as a result he was sent for a CT scan and tests. He was diagnosed with biphasic mesothelioma on 17 September 2020 and died Regulation 28 – Before Inquest Document Template Updated 11/11/2020 from this condition on 13 December 2020. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) In view of Mr Easey’s description of the dust present on the council records in both locations there appears to me a real risk that that these records were, and remain, contaminated with asbestos fibres; (2) Should there currently be asbestos fibres present on the records this presents a risk of asbestos exposure to all those whose come into contact with the records with an associated risk of developing fatal mesothelioma. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 February 15, 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 Chief Coroner and to the following Interested Persons I have also sent it to the solicitors managing Mr Easey’s civil claim, who may find it useful or of interest. Slater and Gordon, Haywood House North, Dumfries Place, Cardiff, CF10 3GA. 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 Dated: 21/12/2020 Bridget DOLAN Assistant Coroner for West Sussex Coroners Service Regulation 28 – Before Inquest Document Template Updated 11/11/2020 Regulation 28 – Before Inquest Document Template Updated 11/11/2020
2 responses 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.
Your Ref:
Our Ref:
1 March 2021
Coroner’s Office
West Sussex Record Office
Orchard Street
Chichester
West Sussex
PO19 1DD
By email only:
Dear Sir/Madam,
Re: Inquest into the death of Brian James Easey
1.
Thank you for your letter of 8 February granting the Council’s request for an
extension of time to reply to the Regulation 28 Report. We are now in a position
to reply to that Report.
2.
In summary, we can inform the Coroner that reports produced by Ayerst, an
external asbestos specialist, following extensive inspections have confirmed
that there is no contamination of the Council’s Registrar files that were once
held at 340 Brixton Road (and at other offices used by the Council’s Registrar’s
Office in the past). Further details are set out below. In view of these findings
the Council does not intend to take any further action.
3.
For present purposes the Council asks the Coroner to note that Mr Easey’s
description of his employment history is disputed, some of the disputed matters
are addressed below.
4.
When the Record of Inquest (“ROI”) was issued on 5 January 2021 there was
no evidence of asbestos contamination either at any of the Council’s premises
or of any Council records. This differed from the situation at the Mill Road
premises owned by West Sussex County Council where asbestos
contamination was confirmed to exist in 1985 (see pages 32-34 of the bundle
previously provided to us by the Coroner’s office). In the circumstances, there
was no basis for the ROI to refer to Lambeth Council at paragraph 3.
5.
Given that the requisite evidence did not exist when the ROI was completed,
and that the Council was not notified of the inquest or given an opportunity to
participate or make any representations to it, and given the findings of the
Ayerst reports, the Coroner is invited to amend (or revoke and re-issue) the
ROI to remove any reference to asbestos exposure during Mr Easey’s
employment with Lambeth Council. The Council asks for a response to this
request within the next seven days.
6.
The remaining paragraphs of this letter contain a more detailed response to the
issues raised.
Ownership of the properties in which the Registrar’s Office was situated
7.
The Council has not owned 340 Brixton Road since at least 1982.
8.
Land Registry records prior to 1982 are unavailable, however, the records show
that 340 Brixton Road was owned by St Thomas’ Hospital Nominees from 1982
and that the property has been owned by Lexadon (Brixton Road) Limited since
11 February 2019, there were other owners in the intervening period.
9.
The Council understands that extensive works were carried out to 340 Brixton
Road (including to the basement where the strong room is said to have been
situated) in or around 2011 when the building was converted into flats. There
is limited information relating to inspections by the Council’s Building Control
department which support this timeframe. There is no suggestion from the
available records that any specialist works were required due to the presence
of asbestos.
10.
The Council sold 357-361 Brixton Road in 2004. The Land Registry records
show that the property is currently owned by Lexadon Limited. Hambrook
House was demolished in 2017.
Mr Easey’s place of work
11. Mr Easey’s witness statement (§7) states that he was employed by the Council
between 1965 to 1984. He states that he was employed as a Registrar and
later a Deputy Superintendent and that “for the duration of his employment” he
was based at 340 Brixton Road (“340”).
12.
It is accepted that Mr Easey was employed by the Council from 1 April 1965
until 31 October 1984 and that he worked for the Registrar’s office but it has
not been possible to verify his job title/description.
13. Mr Easey cannot have been based at 340 for the whole period 1965 – 1984
because the building was not owned by the Council for the whole period.
Further, the location of the Registrar’s Office moved before the building was
sold. Fuller details on these matters are set out below.
Location of Registrar’s Service and records
14.
As advised in our letter of 8 February 2021, 340 Brixton Road was the main
Registrar’s office but there were several satellite offices. For example, in
1967/68 it appears that Mr Easey was Registrar for the Lambeth North Sub-
District and was based at 123 Kennington Road. Between 1971/72 and
1978/79 it appears 340 Brixton Road was used by the Registrar as a marriage
office (only), births and deaths were registered at another building in Lambeth
called Hambrook House and for at least some of those years Mr Easey appears
to have been one of the Registrars of births and deaths (only). In 1979/80 the
Registrar’s service moved to 357-363 Brixton Road which was used for births,
deaths and marriages from this point until 2004 when it moved to Lambeth
Town Hall. The Registrar’s Office remains at the Town Hall but some of the
records have been relocated off-site.
15.
The Registrar’s records date back to circa 1837 and there are approximately
8000 registers in total. The records for the period 1837 – circa 1960 and some
records for subsequent years are kept in two secure air/temperature-controlled
vaults at external sites in Essex (Rainham and Barking) managed by a
company called Restore. The records held in Essex can be accessed by the
Council’s employees on request. The remaining records up to the present day
are kept in a secure vault at the Lambeth Town Hall. Accordingly, there are
three locations at which records are currently stored.
16.
The Council had commissioned detailed reports from external asbestos
specialists in relation to the records held at each of these three locations, some
of which will have been stored at 340 and/or 357-363 Brixton Road at some
point in the past. The results of those tests are set out below under the heading
“outcome of testing”.
Outcome of testing by Ayerst
17.
Ayerst has advised that because the building(s) in which Mr Easey worked are
not available for inspection, the files that may have been kept in the buildings
are the only remaining physical items that can be inspected in order to ascertain
whether there is any future threat to life from anyone accessing the files in
question. This accords with the observations made by the Coroner in her
Regulation 28 Report as to the potential risk presented by asbestos dust
present on records.
18. Out of an abundance of caution, the Council has commissioned detailed
inspections by Ayerst of the files kept at each of the three sites. Ayerst advised
that it would be reasonable to inspect a representative sample of the files (10%
- 800 files) to check for the presence of asbestos. The inspections included
examining any packaging or storage receptacle the files came in. The outcome
of these inspections which included both lab testing of debris found with the
files and air sampling are as follows:
a. Files from Lambeth Town Hall, 1 Brixton Hill, Brixton, SW2 1RW were
inspected on 1-2 February 2021: no asbestos detected
b. Files from Restore, 44 River Road, Barking, IG11 0DW were inspected
during the week commencing 8 February 2021: no asbestos detected
c. Files from Restore, Unit 15 Easter Park, Ferry Lane, Rainham, RM13 9BP
were inspected during the week commencing 8 February 2021 (the selected
files were brought to the Barking Restore site for inspection): no asbestos
detected
d. Air tests done at Lambeth Town Hall (on 11 January 2021) and both of the
Restore sites (on 26 and 27 January 2021) raised no concerns of airborne
asbestos fibres (airborne fibre concentration of less than 0.01 f/ml).
e. Air tests done daily during the above inspections raised no concerns of
airborne asbestos fibres (airborne fibre concentration of less than 0.01 f/ml).
19.
Copies of the reports are enclosed with this letter. We recommend the Coroner
consider the document “Archive Records Investigation” first as this explains the
nature or the extensive inspection conducted by Ayerst. There are four
inspection reports in total as there were two specialists involved in the
inspections of the Town Hall and Restore files and they prepared two reports
each. There is a total of ten air test reports.
20.
The Council is satisfied that its records are not contaminated with asbestos
fibres and that there is no risk to those that come into contact with these files.
21.
As previously advised, the Council has no records of any concerns of
suspicions about asbestos contamination being raised by former or existing
staff or anyone who may have handled the files from the Registrar’s Office. In
the circumstances no further action is proposed.
22. We look forward to hearing from you in relation to the points raised at paragraph
5 of this letter within the next seven days.
Yours sincerely,
Enc.
Principal Lawyer
Legal Services
Phone number (Direct)
Email
County Hall
Chichester
West Sussex
PO19 1RQ
Service of documents accepted by email at
legal.services@westsussex.gov.uk
Mrs Penelope Schofield
Senior Coroner
The Coroners Service
County Record Office
Orchard Street
Chichester
West Sussex
PO19 1DD
Dear Mrs Schofield
Our ref:
By email:
12th February 2021
Re: Regulation 28 Report to Prevent Deaths
Brian James Easey deceased
This letter is prepared by way of respnse to the Regulation 28 Report to Prevent
Future Deaths prior to Inquest received under cover of your letter addressed to
, Chief Executivce, such repsonse being required by the 15th
February 2021.
This response is concerned only with the period of time in which Mr Easey was
employed by West Sussex County Council within the Registration Service which
we confirm from our own records was between the period 1st November 1984
and the 18th February 2006. For the period 1984 to 2000, Mr Easey’s place of
employment was at Mill Road, Worthing where the records of births, deaths and
marriages for the Worthing district were stored. In 2000, all records were moved
to Centenary House in Worthing and at that time, Mr Easey’s employment was at
Centenary House.
In 2010, the West Sussex Registration Service was unified and all records of
births, deaths and marriages inluding those that had been moved from the Mill
Road premises were moved from Centenary House to the County Records Office
in Orchard Street, Chichetster.
Two concerns have been raised within the Regulation 28 Report. The first
concern is that given the description of dust present on council records at Mill
Road, Worthing, there appears to be a risk that such records were and remain
The Legal Services of Brighton and Hove City Council,
East Sussex County Council, and West Sussex County
Council working in partnership
contaminated with asbestos fibres. To respond to this concern, arrangements
were made for air monitoring for asbestos and dust sampling testing to be
undertaken at the location that the records are currently held, that being the
County Records Office. The testing was undertaken by Perry Analytical Limited –
Analytical and Consultant Chemist. Copies of the reports prepared by Perry
Analytical are enclosed.
The registers that are retained at County Records Office in Chichester, are stored
in strong rooms 4 and 5. On the 22nd December 2020 air monitoring for asbestos
tests were undertaken in strong rooms 4 and 5. Two samples for each room
were taken and all samples tested identified an airborne concentration of
asbestos of less than 0.01 fibres per millilitre. The report further comments that
an airborne concentration of less than 0.01 fibres per millilitre is satisfactory,
there only being a need to investigate further where there is a concentration of
0.01 fibres per millilitere or greater.
The samples of dust within strong rooms 4 and 5 were taken on the 31st
December 2020 and analysed on the 4th January 2020. Eleven samples were
taken in room 4 and four samples taken in room 5. The finding for each sample
taken was that no asbestos was identified.
The second concern raised is that should there currently be asbestos fibres
present on the records this presents a risk of asbestos exposure to all those who
come in to contact with the records with an associated risk of developing fatal
mesothelioma. Given that the findings of the air monitoring for asbestos in both
strong rooms identified that the airborne concentration was satisfactory and
secondly that the dust samples did not identify the presence of any asbestos, it
is not appearnt that any one that comes in to conatct with the registers would
have any exposure to asbestos.
It therefore follows that there is no requirement for the council to take any
further action regarding either the location in which the registers are stored or
the registers in question.
The council continue to do whatever it can to ensure the safety of its staff.
Shoud you require any clarification of the points made in this reposse, I would
be grateful if you could please direct any points of clarification to the above
address.
Yours sincerely
Enc: 1. Air Monitoring Test Results
2. Dust Sample Test Results
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