Prevention of Future Deaths reports · 2020

Brian Easey

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 report21 Dec 2020
Reference2020-0293
DeceasedBrian Easey
CoronerBridget Dolan
Coroner areaWest Sussex
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

Responses

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.

Response from Lambeth Legal Services (PDF)
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.
Response from West Sussex County Council (PDF)
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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