Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0048, written 22 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2021 |
|---|---|
| Reference | 2021-0048 |
| Deceased | Jaden Francois-Espirit |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) · Mental Health related deaths · Emergency services related deaths (2019 onwards) |
| 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
Jaden Matthew FRANCOIS-ESPRIT (died 26.08.20)
THIS REPORT IS BEING SENT TO:
1.
Commissioner
London Fire Brigade
169 Union Street
London SE1 0LL
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
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 3 September 2020, I commenced an investigation into the death of
Jaden Francois-Esprit, aged 21 years. The investigation concluded at
the end of the inquest on 15 February 2021. I made a determination of
suicide.
4
CIRCUMSTANCES OF THE DEATH
Jaden hanged himself at home on the 25th or 26th of August 2020. In the
last few weeks of his life he became more withdrawn, including at his
place of work as a firefighter. He felt isolated, though in reality he had
friends there and was well liked, as well as being loved by his family.
5
CORONER’S CONCERNS
1
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.
Unbeknown to those with whom he worked at Wembley Fire Station,
Jaden’s mental well being was deteriorating significantly in the last
weeks of his life, and it deteriorated to the point where he killed himself.
I heard at inquest that the London Fire Brigade has quite sophisticated
systems in place to support firefighters suffering mental ill health.
However, Jaden was not offered the support of, for example,
psychological counselling, because it was not appreciated that he was
so very low.
Obviously if firefighters are to be given the best chance of recovering
from mental ill health, their difficulties first need to be recognised.
I appreciate that it can be difficult to detect that a person may be
depressed or exceptionally unhappy. Signs may be subtle and require a
nuanced approach.
Jaden often complained that he was bored because Wembley Green
Watch had not been called to many incidents. I heard evidence that
boredom in a new firefighter can be quite common. However, I also
heard that a complaint of boredom can be a sign of a person with
dyslexia avoiding an unpalatable or daunting task.
Jaden had dyslexia and was worried that he would not be able to
complete his written work in order to become a fully qualified
firefighter, yet the reality was that his station officer was fully aware
of his difficulties and had tried to reassure Jaden that he was
certainly capable of achieving his goal.
He did need extra time, the space to make mistakes and a degree of
sensitivity that was not always afforded him. On the other hand, he
asked for help and was given a mentor, but did not make use of him
and so eventually the mentorship ceased. That request for help
followed by a refusal of help was not explored. Such an exploration
might have led to a greater understanding of how Jaden could be
helped.
Jaden felt he was being treated unfairly at work and his family have
formed the view that there was an element of racism there, driven in
part by their belief that Jaden was the only non white person on
Wembley Green Watch. Yet the reality was that he joined a watch
where a quarter of the firefighters were people of colour.
2
He described being teased about bringing chicken, rice and peas to
work to eat, thinking that this teasing was because the food was
Caribbean. Looking at this from the outside, chicken, rice and peas
seems a dish without obvious world origin. Moreover, I heard about
a huge variety of food being brought to work by firefighters, with
some even weighing their food before eating. None of this sits easily
with a dish of chicken, rice and peas resulting in a racist comment.
Jaden’s interior life did not always accord with what was going on around
him. Most of all he felt isolated, and yet it was clear to me that he there
was a lot of affection for him at the fire station. He did not always feel
comfortable there. It is not necessarily an easy task to unearth such
feelings in a colleague but, if it results in such a tragedy as this being
avoided, it is a worthwhile one.
I should be grateful if you, or whoever you delegate to investigate this
matter, would listen to the entirety of the recording of this inquest. The
London Fire Brigade investigation report already produced, talks in some
detail about the station culture. There were so many different aspects to
the evidence that, without listening to the whole inquest, I am afraid that
any understanding will not be as meaningful as it could be.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 19 April 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.
HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, Jaden’s mum
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
3
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
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.
9
DATE SIGNED BY SENIOR CORONER
22.02.21 ME Hassell
4
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.
Dllm
I.O Nr,vN F!Rt rmtC.ADE
Coroner ME Hassell
Senior Coroner
ln ner North London
St Pancras Coroner's Court
Carnley Street
London N1 C 4PP
Dear Coroner
1.011dol\ r,1 è Or,g.id~ He,1dqut1ne1::;
'69JnronSt1eel londot'I S.E I Oll
londor- -Ice go ... uk
I hCI LC1nd1m f !lt' Comrr.;v,1p1,,•, 1, 1ht>
fn,· nel '('r',f ,l11lhöuly !(1-1
,•PdO!l
Date 10 June 2021
Response to Regulation 28: Prevention of Future Deaths Report
I write in response to the prevention of future deaths report ['PFD report') you issued following the
inquest touching the death of Jaden Francois-Esprit.
I am grateful that you have noted the contents of the London Fire Brigade ['LFB'J investigation report,
which was produced in response to Jaden's death. As you know that report identified a number of
areas in which the Brigade could better serve its employees, particularly in the initial stages of their
employment.
LFB action plan following Jaden's death
ln advance of the inquest all 24 recommendations in the investigation report were accepted by LFB's
senior leadership team. These were turned into an action plan for change across the organisation. On
receipt of your PFD report the action plan was extended to include the matters of concern raised
therein. so far as they were not already identified by the LFB.
A copy of the plan, with the status of actions as at 10 June 2021, is annexed to this letter.
There are a total of 32 actions which LFB must complete to address the concerns you have raised in the
PFD report and to fulfil the recommendations of its internal report. These have been grouped into the
following 11 broad areas:
(1) Recruitment. Training and Learning Support;
(2) Trans fer System:
(3) Support to FF(D)s whilst at Station;
(4) Finance
(5) Allocation
(6) Other
(7) Support for Death in Service
(8) Culture
(9) Sharing the findings
(10)Proactively Identifying Mental lii-Health
(11 )Further investigation
Responsibility for each action has been assigned to a senior leader in the Brigade (i.e. Commissioner,
Assistant Commissioner or Assistant Director) with a named senior officer tasked to complete the
required work. Completion dates have been set for each action.
Of the 32 items listed on the plan nine have been completed. The remaining 23 are expected to be
concluded in line with either the target date set or a revised date. which will be monitored by the
People Board.
The action plan is a standing item at the monthly People Services Board. led by the Director of People
and attended by all Directors of LFB. This provides the scrutiny required to ensure completion of all
agreed actions. Accordingly, all outstanding items will continue to be closely monitored.
I hope this response provides you with the necessary assurance of the LFB's commitment to further
improving the mental health of all its staff.
London Fire Commissioner
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.