Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0016, written 20 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2021 |
|---|---|
| Reference | 2021-0016 |
| Deceased | Philip Sheridan |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | Community health care · 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. 3. The Secretary of State for Housing, Communities and Local Government, 2 Marsham Street, London, SW1P 4DF 1 | CORONER | am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (E). 2 | 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. 3 | INVESTIGATION and INQUEST On 16% August 2019 | commenced an investigation into the death of Philip Noel Sheridan, aged 32. The investigation concluded at the end of the Inquest on 5 January 2021. The Inquest concluded with a Narrative Conclusion recording that his death on 6" July 2019 was attributable to the complications of smoke inhalation arising from a fire on 26th June 2019 in the cellar flat where he lived alone. 4 | CIRCUMSTANCES OF THE DEATH Philip Noel Sheridan had begun cooking in his cellar flat around midnight on 25/26 June 2019, but had then probably fallen asleep. Around 0300 on Wednesday 26" June 2019 a fire was discovered. He managed to get out of the flat and up to street level but then collapsed. Despite treatment in a specialist burns intensive care unit he continued to deteriorate and died on Saturday 6" July 2019 at Pinderfields Hospital, Wakefield. At the time of the fire there was no smoke detector fitted in his cellar flat. There was only one exit door which had no handle fitted to it and was situated next to the seat of the fire on the hob, thus necessitating him being in close proximity to the fire and smoke when trying to escape. The cellar flat conversion had taken place without: (a) Planning consent; (b) Building Regulation approval; (c) Leeds City Council Housing Department being informed of the existence of the cellar flat as a separate dwelling. In consequence no regulatory authority had inspected the cellar flat. Had they done so it is likely an Emergency Prohibition Order would have been served in view of the hazards present. 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) | an Assured Shorthold Tenancy Agreement with the deceased on 14" August 2013. He was a ‘person in control’ of the cellar flat within the meaning defined in the Housing Act 2004. He and/or were involved in the management of other properties in the Leeds area in the period 2013-2019. He or they should have been aware that the cellar flat did not have planning consent, Building Regulation Approval and had not been inspected by Leeds City Council Housing Officers. The evidence taken at the Inquest gave rise to a concern on the balance of probability that the hazards identified in the cellar flat may be replicated in other properties managed by them, particularly in relation to the provision of smoke detection equipment or emergency escape routes in the event of fire. 2) Leeds Citv Council made payments relating to Local Housing Allowance direct to EE oaiin £9462.05 in respect of the cellar flat which had taken the address of en] Leeds. This was done without ascertaining whether the cellar flat had planning consent, Building Regulation Approval or had been inspected by Leeds City Council Housing Officers to establish whether it was safe for human habitation. Evidence taken at the Inquest indicated there were many other comparable properties in Leeds. This situation gives rise to a concern that fire hazards may be present in respect of properties which may have the appearance of being approved by virtue of the award of Local Housing Allowance. 3) Evidence taken at the Inquest indicated that whilst a Landlord has an obligation to provide smoke detection devices at the inception of a tenancy, there was no ongoing duty to ensure they continued to be effective or replace them if found to be faulty. In this case the tenant had resided in a cellar flat for nearly six years, before he sustained injuries in a fire which proved fatal. There was no smoke alarm in the cellar flat at the time of the fire on 26" June 2019. | am concerned that the laudable statutory objective enshrined in The Smoke and Carbon Monoxide Alarm (England) Regulations 2015 is undermined if a landlord is not required to check periodically such devises are still effective. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you and your respective organisation 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 26' March 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. COPIES and PUBLICATION i have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 4) He Siste: of the deceased on behalf of his family. 2) West Yorkshire Police, FAO D/S 3) West Yorkshire Fire and Rescue Service, yey st 4) Leeds City Council, Housing Department FAO: i Principal Housing Officer). | have also sent it to the following who may find it useful or of interest: 4) E (Gas and Electricity) Ltd. 2) Leeds City Council, Council Tax Section, ae SY 3) Sunday Mirror Newspapers 4) Yorkshire Post Newspapers | 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. Signed: ; final Keron para a fs Kevin McLoughlin Senior Coroner West Yorkshire (E) Dated: 20" January 2021
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.
ay Ministry of Housing, Communities & Local Government Rt Hon Robert Jenrick MP Secretary of State for Housing, Communities and Local Government Ministry of Housing, Communities and Local Government Fry Building 2 Marsham Street London SW1P 4DF www.gov.uk/mhclg Kevin McLoughlin Senior Coroner, West Yorkshire (Eastern) Coroner’s Office & Court 71 Northgate Wakefield West Yorkshire WF1 3BS February 2021 PRO TI Thank you for your letter of 20 January enclosing a Regulation 28 Report in relation to the inquest touching the death of Philip Noel Sheridan. | am saddened to hear of Mr Sheridan’s death in these tragic circumstances. The Government is very clear that unauthorised development and failure to comply with Building Regulations is unacceptable. Day to day responsibility for planning control rests with local planning authorities. We have recently funded the National Association of Planning Enforcement (NAPE) to produce guidance to help authorities carry out their enforcement functions. This guidance sets out the wide range of powers available and provides advice about their use in practice. In particular, local authorities have various powers to request information about the ownership and use of land. NAPE’s guidance contains examples of sources of information that authorities may draw upon, including things such as housing and council tax records. As part of our reform of the planning system, we are keen to see a stronger emphasis on planning enforcement. Our recent ‘Planning for the Future’ White Paper sets out our intention to introduce stronger enforcement powers and to look at ways of supporting more enforcement activity. The Building Regulations can be contravened by not following the correct procedures or not meeting the required technical performance requirements. Under Sections 35, 35A and 36 of the Building Act the local authority has the power to take enforcement action against the building owner and those carrying out the works. This can include requiring that the works are pulled down or removed. We are currently consulting on proposals to extend the Smoke and Carbon Monoxide Alarm (England) Regulations 2015. We are proposing to mandate smoke alarms in all socially rented homes. Social landlords would be obliged to provide a smoke alarm on each storey of the premises on which there is a room used wholly or partly as living accommodation. This would bring requirements in line with those for private landlords. We are also proposing to amend the legislation to create an obligation for social and private landlords to repair or replace smoke alarms, once informed that they are faulty. We are not proposing to require landlords to test smoke alarms throughout the life of a tenancy. The consultation ran for 8 weeks from 17 November 2020 and closed on 11 January 2021. We are currently analysing the responses and will publish our response in due course. L/t2~+ ; a , Ly RT HON ROBERT JENRICK MP
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