Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0227, written 2 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2021 |
|---|---|
| Reference | 2021-0227 |
| Deceased | Henry Boddy |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Community health care · Other related deaths |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Lord Greenhalgh Minister of State for Building Safety, Fire and Communities Ministry of Housing Communities & Local Government and Home Office Fire Safety Unit, Home Office, 2 Marsham Street, Fry Building London SW1P 4DF 1 CORONER I am R Brittain, Assistant Coroner for Inner London North. 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 INVESTIGATIONS and INQUESTS Mr Henry Boddy died on 4 November 2020 at University College London Hospital. I concluded an inquest to his death on 25 June 2021, with the following wording: Mr Boddy died form the consequence of a fire at his own residence. This arose from recognised risks, on the background of health conditions from which he suffered. There were missed opportunities to address these risks but that does not amount to neglect. 4 CIRCUMSTANCES OF THE DEATH Mr Boddy was found collapsed on 4 November 2020 in his own property, at which there was a significant fire ongoing. He was rescued by London Fire Brigade, resuscitated by London Ambulance Service and treated in hospital. However, he died later the same day from the consequences of this fire, which was later found to have been caused by either unsafe use of candles for lighting or unsafe use/disposal of smoking materials. The condition of his flat had previously been recognised to pose a fire risk, owing to the accumulation of a fire load because of hoarding behaviour. This had been ongoing for many years. Multiple concerns had been raised about this risk and steps taken to address it. However, his hoarding behaviour continued and the risk recurred. Much of the evidence I heard at the inquest related to steps taken or not taken, in order to address these ongoing risks. I was satisfied that the London Borough of Camden have taken or are taking steps to address the matters of concerns raised. However, one issue remained unaddressed, as it relates to matters outside of the council’s control. I heard evidence that statutory powers do not exist to address concerns regarding 1 fire risk as a consequence of hoarding, in a residential property. A witness from the council set out that fire safety issues can only be addressed through contemporaneous enforcement of Environmental Health powers, under legislation intended to address infestation. In this circumstance, Environmental Health officers did not attend the property nor address concerns about infestation with rodents, as it was (in retrospect inappropriately) felt that there was insufficient evidence provided. 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. I am aware that the Government has recently consultant on and responded to potential additional fire safety measures. However, from the evidence I heard at this inquest and from my review of the Government’s response, I am concerned that there is a gap in enforcement powers, as they relate to addressing fire risks in residential properties; specifically in this circumstance, the risks of a fire load arising from hoarding behaviour. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees 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 27 August 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, Mr Boddy’s family, London Borough of Camden – Social Services department, London Fire Brigade. 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: 2 July 2021 Assistant Coroner R Brittain 2
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.
Lord Greenhalgh Minister of State for Building Safety, Fire and Communities 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Richard Brittain Assistant Coroner for Inner London North London Borough of Camden Regulatory Services Camley Street N1C 4PP 27 August 2021 Dear Richard, Regulation 28: Report to prevent future deaths I refer to your report (dated 2 July 2021) provided in accordance with your duty under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following your inquest into the very sad death of Mr Henry Boddy. I must offer my sincerest condolences to the family and friends of Mr Boddy. I understand that the inquest concluded that Mr Boddy died from a fire at his own home, which was later found to have been caused by either unsafe use of candles for lighting or unsafe use or disposal of smoking materials. Your report also raises concerns regarding the fire risks as a consequence of hoarding in Mr Boddy’s home and about a potential gap in enforcement powers with regards to the risks of a fire load arising from hoarding behaviour The Regulatory Reform (Fire Safety) Order 2005 (the “Fire Safety Order” (FSO)) covers fire safety in workplaces and other non-domestic premises. In residential buildings, the FSO applies to communal areas (the “common parts”) but not individual homes or flats themselves (although Prohibition Notices can restrict or prohibit access to domestic premises of more than one dwelling where use poses serious risk to relevant persons.) The FSO imposes duties on the responsible person. The responsible person is defined as a person in control of the premises, which could include the employer, the trade or business occupier, the building owner or managing agent. The responsible person’s duties include: • Carrying out a fire risk assessment of the premises and reviewing it regularly • Taking general fire precautions to ensure safety Article 5(3) of the FSO provides that any duties imposed on the responsible person under the FSO, or by regulations made under the Order, shall also be imposed on every other person who has to any extent control of relevant premises so far as the requirements relate to matters within their control. This includes: • A person with obligations of any extent under a contract or tenancy in relation to maintenance or repair of premises or the safety of any premises (depending on the circumstances, a tenant could breach their obligations through hoarding behaviour), and • Such a person is to be treated as a person having control of the premises to the extent of the obligation. Local Fire and Rescue Authorities (FRAs) are the enforcing authority for the majority of buildings to which the FSO applies, including for the common parts of residential buildings. FRAs are operationally independent to Government and decisions on compliance and enforcement of the FSO rests with them. FRAs exercise their discretion when exercising their powers to take enforcement action. When undertaking an inspection and becoming aware of hording behaviour an FRA could foreseeably decide that such behaviour by a resident posed serious fire safety risk to them and other residents including their means of escape in the event of a fire. Similarly, hoarding of dangerous or non-dangerous material could present a serious fire hazard. If an FRA considers that such behaviour poses such a risk they can issue a prohibition notice on a responsible person (or any other person mentioned in article 5(3)), if the fire risk is so serious that the use of the premises needs to be prohibited or restricted due to the risks posed by hoarding behaviour. FRAs need to consider if a prohibition notice is the most appropriate and proportionate approach to address the risk identified. For example, individuals with hoarding behaviour could be vulnerable and may have mental health issues. If FRAs were to restrict access to their homes, this could have a significant impact on vulnerable individuals - not limited to those with hoarding behaviour. This could disproportionately impact those with a disability under the Equality Act 2010 and potentially cause greater harm to vulnerable individuals. Therefore, enforcement under the FSO might not be the most appropriate and proportionate action to address fire safety risks caused by hoarding, but this would depend on the circumstances. However, Safe and Well Visits are carried out by FRAs in accordance with section 6(1)(b) of the Fire and Rescue Services Act 2004 with regards to giving advice on request on how to prevent fires and restrict their spread and means of escape from buildings and other property in case of a fire. Safe and Well visits comprise of FRAs visiting people in their own homes to provide them with tailored fire safety and risk reduction advice. Where risks are identified, which cannot be dealt with by FRAs, we expect them to work closely with other local public services through existing local arrangements -such as multi-agency safeguarding hubs - to ensure appropriate action can be taken to protect vulnerable individuals as well as other residents. Therefore, a more appropriate and proportionate approach for addressing fire safety risks as a result of hoarding could be a multi-agency approach working towards a long-term solution, rather than enforcement. This could include, for example, local authorities, FRAs and social services work collaboratively to ensure that individuals with hoarding behaviour have the right level of support and ensure that the fire safety risks are reduced. FRAs may also raise safeguarding referrals following a Safe and Well visit, where they believe a resident is at risk from neglect or abuse in line with the Care Act 2014. This includes referrals for self-neglect following significant changes to the Care Act 2014 which now include self-neglect under the legal definition of abuse or neglect relevant to individuals with care and support needs. Lord Greenhalgh Minister of State for Building Safety, Fire and Communities at Ministry of Housing, Communities & Local Government and Home Office
See every Prevention of Future Deaths report matching Community health care, 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.