Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0108, written 14 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Apr 2021 |
|---|---|
| Reference | 2021-0108 |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | 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. The Rt. Hon Kwasi Kwarteng MP Secretary of State Dept. for Business, Energy and Industrial Strategy 1 | CORONER | am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East) 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 29 December 2017 | commenced an investigation into the death of Richard John Dyson aged 38 and Simon Brian Midgley aged 36. The investigation concluded at the end of the Inquest on 14 April 2021. The conclusion of the Inquests was that both men were unlawfully killed as a result of: 1(a) Inhalation of smoke and fire gases 1(b) Hote! Fire 4 | CIRCUMSTANCES OF THE DEATH Mr Dyson and Mr Midgley were guests staying at the Cameron House Hotel, Loch Lomond on the weekend of 16-18 December 2017. Around 6.30 am on Monday 18 December 2017 a fire broke out in the hotel. The two men were found in an unresponsive condition after 8 am by firefighters wearing breathing apparatus. They were pronounced dead later that morning. 5 | CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. tn 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) Every hotel should have a readily accessible and accurate list of the guests and staff members in the establishment on a particular night. In an emergency situation it is imperative that the Fire and Rescue Service are provided with accurate information speedily in case anyone remains trapped in the building. It is a situation where every second counts. (2) Itis foreseeable that in the stressful atmosphere of an emergency, people may hesitate or make mistakes. In this case, forgetting to take the guest list as the building was evacuated. In consequence, although the Fire and Rescue Service had arrived at the hotel by 6.51 am, it was not until sometime after 8am that it was established two guests were missing. Critical time was lost before rescue efforts began to find them. The precise times cannot be provided as the Procurator Fiscal was not willing to disclose copies of witness statements or reports on the ground they were confidential. (3) To avoid needless impediments to rescue efforts, it would be prudent for hotels to have an electronic system such as SharePoint which would enable the emergency services to gain prompt access to such vital information. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 14 June 2021. |, 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 | have sent a copy of my report to the Chief Coroner. | have also sent it to the following who may find it useful or of interest: 3) UK Hospitality Association 4) Health and Safety/Local Authority Enforcement Liaison Committee 5) Local Authorities Health and Safety Practitioners Forum 6) National Fire Chiefs Council 7) Crown Office and Procurator Fiscal Service 8) Cameron House Resort (Loch Lomond) Limited 9) Media representatives | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both ina 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. Dated: 14" April 2021 Signed: Ker MHeukke. KEVIN McLOUGHLIN Senior Coroner West Yorkshire (E)
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.
Ministear airson Sàbhailteachd Coimhearsnachd Minister for Community Safety Ash Denham BPA/MSP Kevin McLoughlin ___ 11 June 2021 Dear Mr McLoughlin, Thank you for sending on your Regulation 28 report regarding the Cameron House Hotel fire. Strengthening fire safety remains a priority and the Scottish Government continues to support the Scottish Fire and Rescue Service’s (SFRS) work to reduce fires and fire fatalities. This includes learning from incidents and investigations, including your report, albeit Regulation 28 of the Coroners (Investigations) Regulations 2013 does not extend to Scotland (the coroner system only applying in England and Wales). The following is a summary of the safety actions for Scotland that have and will be taken following the fire. The Scottish Government’s Fire safety guidance for existing premises with sleeping accommodation was published in 2018. The guidance was produced to assist those who have responsibility under the Fire (Scotland) Act 2005 for fire safety in certain premises with sleeping accommodation in Scotland. It recommends that the premises management should have an Emergency Fire Action Plan in place specific to the premises that should include procedures for: checking whether the premises have been evacuated; and for meeting the SFRS and passing on details of the incident, including whether all persons are accounted for. The Scottish Government will work with SFRS to consider updating the guidance to make it more explicit that an accurate guest list, whether paper or digital, should be maintained to aid in ensuring all guests are evacuated; as well as for passing on relevant details to SFRS. In terms of the actions taken by SFRS following the fire, operational matters are for SFRS. Scottish Ministers appoint a Chair and other members to serve as members of SFRS, collectively referred to as the Board. The Board provides strategic direction, support and guidance to the SFRS ensuring that it operates effectively and that the Scottish Government’s priorities are implemented. Tha Ministearan na h-Alba, an luchd-comhairleachaidh sònraichte agus an Rùnaire Maireannach fo chumhachan Achd Coiteachaidh (Alba) 2016. Faicibh www.lobbying.scot Scottish Ministers, special advisers and the Permanent Secretary are covered by the terms of the Lobbying (Scotland) Act 2016. See www.lobbying.scot Taigh Naomh Anndrais, Rathad Regent, Dùn Èideann EH1 3DG St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.gov.scot SFRS regularly inform my officials of the actions they are taking to strengthen fire safety in the hotel accommodation sector including: Refreshing wider prevention and protection awareness within SFRS and disseminating key points from the investigation internally. Working with the hotel sector to ensure that lessons are learned. Engaging with Dutyholders to ensure they are aware of their fire safety responsibilities and the potential consequences of failing to address any shortcomings. Preparing a public education campaign on fire action plans and escape routes. SFRS Enforcement Officers continue to support and advise those responsible for the safety of their premises wherever possible to achieve compliance in line with the Scottish Regulator’s Strategic Code of Practice. I will ensure I receive updates from SFRS on hotel fire safety during our regularly scheduled meetings throughout the year. I hope this response is helpful to you and thank you again for taking the time to send on your recommendation. ASH DENHAM Tha Ministearan na h-Alba, an luchd-comhairleachaidh sònraichte agus an Rùnaire Maireannach fo chumhachan Achd Coiteachaidh (Alba) 2016. Faicibh www.lobbying.scot Scottish Ministers, special advisers and the Permanent Secretary are covered by the terms of the Lobbying (Scotland) Act 2016. See www.lobbying.scot Taigh Naomh Anndrais, Rathad Regent, Dùn Èideann EH1 3DG St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.gov.scot
See every Prevention of Future Deaths report matching Kevin McLoughlin, 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.