Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0205, written 16 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Jun 2021 |
|---|---|
| Reference | 2021-0205 |
| Coroner | Emma Serrano |
| Coroner area | Stoke-on-Trent & North Staffordshire |
| Category | Community health care · Other related deaths · Child Death (from 2015) |
| 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 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. City Director Stoke-on-Trent City Council Civic Centre Glebe Street Stoke-on-Trent ST4 1HH 1 CORONER I am Emma Serrano Area Coroner for Stoke-on-Trent & North Staffordshire Coroner's Court 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 11/10/2017 I commenced an investigation into the death of Zainab Adam Bargo Hashim (“Zainab”), aged 36 and Tafaoul Abdulillia Abdulkarim (“Tafaoul”), aged 6. The investigation concluded at the end of the inquest on 11th June 2021. The conclusion of the inquest was a narrative conclusion detailing that both Zainab and Tafaoul died from the effects of inhalation of smoke fumes, in the communal area of the block of flats, whilst attempting to flee a fire that had started in a separate flat. The Medical Cause of death after Post Mortem is : Zainab 1a) Hypoxic/ischaemic brain injury due to inhalation of fire fumes Tafaoul 1b) Complications of inhalation of fire fumes (including hypoxic/ischaemic brain damage). 4 CIRCUMSTANCES OF THE DEATH Zainab Adam Bargo Hashim passed away at the Royal Stoke University Hospital, Stoke-on-Trent on the 2 October 2017 from ‘Hypoxic/ischaemic brain injury due to inhalation of fire fumes’. Tafaoul Abdulilla Abdulkarim passed away two days later on the, on the 4 October 2017 from ‘Complications of inhalation of fire fumes (including hypoxic/ischaemic brain damage)’. Ringland Close, because a On the 1 October 2017 Zainab left her home address home address of fire had started in of the same block. To leave the block she had to go into the communal area of the block of flats which had become filled with smoke and fire fumes. The fumes caused Zainab, and her , who was 6 months old, to collapse, and children, Tafoul, who was 6 years old, and become unconscious. All were rescued by the Fire Service and taken to the Royal Stoke University Hospital where Zainab and Tafaoul passed away. 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. – During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help. It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy. During this particular incident no residents had stayed within their property. No residents were aware of the two the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties. Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you Stoke-on-Trent City Council 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 1 October 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: husband to Zainab Adam Bargo Hashim and father to Tafaoul Abdulilla Abdulkarim 1) 2) 3) 4) Staffordshire Fire Service. I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. 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 16/06/2021 Emma Serrano Area Coroner Stoke-on-Trent & North Staffordshire Coroner's Court
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.
Your reference
Date
30 September 2021
Ms E. Serrano
Area Coroner (Stoke-on-Trent & Staffordshire)
HM Coroner’s Office
Stoke Town Hall
Kingsway
Stoke-on-Trent
Staffordshire
ST4 1HH
Dear Ms Serrano
City Director’s Office
Civic Centre
Glebe Street
Stoke-on-Trent
ST4 1HH
Regulation 28 Report - Zainab Adam Bargo Hashim and Tafaoul Abdulillia Abdulkarim
In response to your Regulation 28 Report to Prevent Future Deaths dated 16 June 2021 following the
inquest into the deaths of Zainab Adam Bargo Hashim and Tafaoul Abdulillia Abdulkarim this letter
sets out how Stoke-on-Trent City Council communicates its Stay Put Policy to residents who live in
council owned blocks where a Stay Put Policy applies (“Stay Put Blocks”) post October 2017, the
frequency of that communication and planned future actions.
How the Stay Put Policy is communicated
All residents in Stay Put Blocks receive a copy of the Fire Safety Notice (Appendix A) produced in
partnership with Staffordshire Fire and Rescue Service which sets out concisely what they should do
in the event of a fire.
The Fire Safety Notice is translated and provided to tenants in their first language. Such information
is obtained from tenants when they sign up to the Council’s Housing Waiting List. The Council
routinely translates the Fire Safety Notice into the 14 languages that are commonly spoken within
the city (Czech, Polish, Russian, Bengali, Urdu, Arabic, Farsi, Kurdish, Mandarin, Pashto, Punjabi
Pakistan, Punjabi Indian, Slovak and Turkish) and any others as may be required (Appendix B).
The Fire Safety Notice which communicates the Stay Put Policy in English is displayed prominently in
communal areas on every floor of every Stay Put Block within the city. It also communicates the
circumstances in which ‘Stay Put’ should be abandoned i.e. if smoke or heat affects a resident’s
home or if they are instructed to leave by the fire and rescue service.
The Stay Put Policy is verbally communicated to tenants of the Stay Put Blocks when an annual
Tenancy Audit Visit is carried out by Housing Officers. Housing Officers are trained on Fire Safety
Awareness and how to communicate the Stay Put Policy. This training is refreshed annually.
The Council has updated its Fire Safety Scripting Note, which is used by Housing Officers to deliver
the Stay Put Policy during the Tenancy Audit Visit, to ensure consistency. It now requires Housing
Officers to hand out the Fire Safety Notice and ask tenants the following questions:
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i.
ii.
iii.
Do you know there is a Stay put policy;
Do you understand the Stay Put Policy; and
Do you know that as a tenant you are responsible for advising other members of their
household / visitors about the Stay Put Policy?
The Tenancy Audit form requires tenants to sign to confirm they are aware that there is a Stay Put
Policy.
Housing Officers do not sign off a Tenancy Audit Visit and leave a tenant’s flat until they are satisfied
that a tenant has fully understood the Stay Put Policy.
Tenants are asked to sign a written declaration at the start of their tenancy, at the 6 week New
Tenancy Visit and all subsequent Tenancy Audits to record they have received the following
information:
-
-
-
-
fire safety information (including the Stay Put Policy) has been provided and fully explained
to them;
the language the fire safety information was provided,
that they have understood the fire safety information and
they will provide this information to all members of their household to ensure that they also
understand the importance of fire safety.
Where English is not a tenant’s first language, the Lettings staff will employ the services of a
translator to attend Sign Up Visits with them to translate the Stay Put Policy (amongst other things)
and to interpret any questions asked. This service is free of charge to tenants. This process is
recorded in a recently developed Fire Safety Advice Check List. If a tenant requires ongoing
translation support at Tenancy Audit Visits this is provided by arranging for the attendance of family
and friends who speak English or if necessary the services of a professional translator will again be
provided by the Council.
To ensure the Stay Put Policy is communicated effectively to residents of Stay Put Blocks who may
have a learning style not suited to text information, the Fire Safety Notice also contains illustrative
imagery next to key points. This also helps to reinforce understanding.
Housing Officers ensure that they communicate to tenants with disabilities in a manner which is best
suited to their needs, using written or verbal communication and also the support of family and
friends or other Council department / other agencies as appropriate.
For tenants with disabilities who are likely to require additional support to evacuate in the event of a
fire the Council requests that Staffordshire Fire and Rescue Service carries out a fire safety visit to
their flat to reinforce the Stay Put Policy and to discuss how they would evacuate if required to do so
by the fire and rescue service. This is in addition to the person-centred risk assessments carried out
by the Council on all tenants as part of Tenancy Audits.
For tenants who are hard to engage the Council’s Housing Officers work closely with other Council
Departments (e.g. Adult Social Care), trusted stakeholders including Staffordshire Fire and Rescue
Page 3
Service, Staffordshire Police, Mental Health Support Workers and General Practitioners to arrange
joint visits. As a recent example of this, Housing Officers conducted a joint visit with Staffordshire
Fire and Rescue Service and Staffordshire Police to provide reassurance around the Stay Put Policy.
In addition to the above, Proactive Calls to tenants have been introduced whereby the Council will
attempt to contact all tenants by telephone and discuss fire safety and to check understanding
about the Stay Put Policy where appropriate amongst other matters. This method of communication
is also used to update our records of any changes in the tenant’s details, and listen to tenant’s views
on how safe and secure they feel.
The Council has a Tenant Board which represents the diverse demographic residing in Council owned
and managed social housing in Stoke-on-Trent, with the purpose of giving tenants a voice on key
aspects of housing management. The seven Tenant Board Members are involved in how the Stay Put
Policy is communicated and recently participated in trialling the Proactive Calls.
A copy of the Fire Safety Notice is sent to all leaseholders and the Stay Put Policy is also a standing
item in the Leaseholder Newsletter.
The Council holds community events which include fire safety (which Staffordshire Fire and Rescue
Service attend), to which residents are invited. These community events are held at various locations
across the City and are widely publicised to ensure maximum uptake.
The Council has facilitated Staffordshire Fire and Rescue Service attending the surgeries of local
councillors in Stoke-on-Trent to reinforce the importance of Stay Put.
The Council also promotes the following services provided by Staffordshire Fire and Rescue Service
to its residents:
-
-
to attend Resident Association meetings,
Community Advice Team which now offers a free home fire safety checks via a free phone
telephone number (0800 0241 999 lines are open from 8am-5pm, Monday to Friday).
Following the publication of the Government’s White Paper on social housing: The charter for social
housing residents in November 2020 which was developed following the tragic fire at Grenfell
Tower, the Council has developed a Customer Engagement Strategy which aims to deliver the
expectations contained within that charter with particular emphasis on ensuring tenants have a
voice and are heard.
Frequency of how the Stay Put Policy is communicated
The Fire Safety Notice is provided to all new tenants when they sign-up for their tenancy along with
a copy of a Home Office produced Fire Safety Poster (Appendix C), the Fire Safety Scripting Note and
the Fire Safety Check List.
To ensure the Stay Put Policy is regularly communicated Fire Safety Letters and Fire Safety Notices
are given by hand to all new tenants at tenancy sign up. A further copy of the Fire Safety Notice is
handed to tenants at the 6 weeks new tenancy visits, again at 6 months and then going forward to
all tenants every 12 months, as part of annual Tenancy Audit Visits.
If at any time Housing Officers struggle to gain access to a flat the Fire Safety Notice will be put
through the letter box (translated into their first language) or it will be emailed to the tenant if that
is their preferred method of communication.
Page 4
The Council continually adapts and improves how it communicates with its residents and when
COVID 19 restrictions have prevented home visits, telephone calls have been made to tenants to
discuss fire safety and fire safety notices have been posted through letter boxes.
A copy of the Fire Safety Notice is sent to leaseholders at the time they purchase the property from
the Council through Right to Buy scheme and when the leaseholder sells their interest on the open
market. Leaseholders also receive the Leaseholder Newsletter annually.
Action to be Taken
The Chair and Vice Chair of the Tenant Board will accompany Council Housing Officers when they
conduct Fire Safety Audits of Stay Put Blocks. They have received Fire Safety Awareness Training in
preparation for this role.
The Council will continue to be guided by the information and best practice shared at its Fire Safety
Group Meetings at which Staffordshire Fire and Rescue Service attend.
We have just consulted on our Customer Engagement Strategy and will consider all feedback.
Housing Officers undertaking Tenancy Audit Visits will be required to undertake enhanced training
on communicating with tenants who don’t speak English as a first language.
We are also in the formative stages of developing a video on fire safety and Stay Put and a series of
questions and answers to help to communicate the Stay Put Policy to residents with different types
of learning styles. It is intended that the video will be watched during the application process for
Council housing by those who have been offered a Council property and be available to all tenants.
Fire Safety Notices will be posted through the letterbox of all leaseholder properties and
leaseholders will be made aware that it is their responsibility as landlord to make sure that their sub-
tenants are aware of the Stay Put Policy and understand it. This will start with immediate effect.
The Council will review the frequency of how it communicates with leaseholders around fire safety
and Stay Put.
The Council has a provisional plan in place for leaseholders to be sent fire safety information with
council bills, by way of an additional reminder.
The Council will consider increasing the use of targeted digital communication methods to convey
the message of Stay Put to residents in Stay Put Blocks e.g. including this information in mast
banners, signature boxes, tenants e bulletins and rent bills.
The Council is also exploring the effectiveness of also displaying an additional notice in communal
areas of all Stay Put Blocks explaining that the Fire Safety Notice can be requested in other
languages.
More in depth questioning will be undertaken of tenants in Stay Put Blocks, of their understanding
of the Stay Put Policy. Feedback obtained will be used to inform the Council’s communication
strategy around fire safety going forward.
Conclusion
We thank you for the concerns that you have raised. Stoke-on-Trent City Council places a very high
level of importance on fire safety, as demonstrated by our commitment to communicating the Stay
Put Policy to our residents effectively and our investment in other fire safety measures such as
sprinkler systems. We also await the coming into force of new legislation and the publication of
further national guidance later this year in relation to fire safety in blocks of flats as a result of the
Grenfell Tower Inquiry and the Government consultation on Personal Emergency Evacuation Plans in
High Rise Residential Buildings and will be monitoring these changes, seeking professional support
to implement them and ensure that staff receive formal training on the new legislation and
guidance.
Page 5
Yours sincerely
City Director
Appendix A
Appendix B
APPENDIX C
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