Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0284, written 26 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Aug 2021 |
|---|---|
| Reference | 2021-0284 |
| Deceased | James Golds |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Care Home Health related deaths · 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: Secretary of State for Department of Communities, Housing and Local Government 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 INVESTIGATION and INQUEST On 1st October 2020 I commenced an investigation into the death of James Golds. The investigation concluded on the 21st July 2021 and the conclusion was one of accident. The medical cause of death was 1a Respiratory failure secondary to smoke inhalation; II 17% total body surface area burns, chronic obstructive pulmonary disease 4 CIRCUMSTANCES OF THE DEATH Millom Court. He was vulnerable James Frederick Golds lived at Flat and had become increasingly confused prior to 28th September 2020. He was a known smoker and there had been concerns relating to how he managed the risks of smoking. On 28th September 2020 emergency services were called to the address for a reported fire. James Golds was rescued from his flat by the fire service. He was taken to Wythenshawe Hospital with significant fire related injuries. He deteriorated and died at Wythenshawe hospital from the complications of smoke inhalation. The cause of the fire was identified as an accident caused by a cigarette discarded whilst he was confused. 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. 1 The MATTERS OF CONCERN are as follows. – 1. From the evidence before the court it was clear that Mr Golds presented a significant risk of accidentally starting a fire. He resided in accommodation occupied by vulnerable members of the community who needed some support to live independently. The Court heard that there was little guidance for facilities such as his about how the risk of fire should be managed and escalation of such risk. 2. In addition in relation to the design and fire prevention features for such accommodation the inquest heard that there was no statutory requirement for sprinkler systems. Smoke detectors were in the hallway areas of each flat but because of the way in which a cigarette related fire developed the detector would not be triggered until the fire was well established. This made it difficult to escape and increase the risk of the fire spreading further. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 21st 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 (family of the deceased), Interested Persons namely, who may find it useful or of interest. 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. 2 9 26th August 2021 Alison Mutch HM Senior Coroner Greater Manchester South 3
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.
.,W,. ~ Department for Levelling Up, Housing & Communities Alison Mutch HM Coroner - Manchester South Coroners Court 1 Mount Tabor Street Stockport Cheshire SK1 3AG Rt Hon Michael Gove MP Secretary of State for Levelling Up, Housing and Communities Minister for Intergovernmental Relations Department for Levelling Up, Housing and Communities 4th Floor, Fry Building 2 Marsham Street London SW1 P 4DF www.gov.uk/dluhc 2/ft October 2021 Thank you very much for your letter and report of 26 August 2021 provided in accordance with Regulation 28 of the Coroners (Investigations) Regulations 2013, following your inquest into the death of James Golds on 28 September 2020. I am very sorry for the delay in replying, which was I take our due to an administrative error, which I understand my officials have explained to you. responsibilities in considering your reports very seriously. I would like to take this opportunity to offer my sincere condolences to the family and friends of Mr Golds following this very sad incident. You have recommended that I, in my capacity as the Secretary of State, should consider requiring mandatory installation of sprinkler systems in accommodation provided for vulnerable people. You also raise the availability of guidance for the management of risk in premises for vulnerable people. Regarding sprinklers specifically, in November 2020 the Government brought forward changes to the guidance to the Building Regulations with regards to fire safety (Approved Document B) reducing the height threshold at which sprinkler systems are provided in new blocks of flats from 30 metres to 11 metres and greatly increased the number of future homes provided with sprinkler protection. This was the first step in a full technical review of Approved Document B, which will include research to ensure that any changes to this guidance is based on a robust evidence base. The technical review programme includes a workstream reviewing the current provisions for new specialised housing and care homes such as the one in which Mr Golds resided. Alongside this review of requirements for new homes, the new safety case review regime being brought forward in the Building Safety Bill will inform decisions on retrofitting sprinklers in existing high-rise buildings in scope. This approach will ensure that the layers of protection provided are tailored to the risks in each building . There are also number of provisions already in place to try to ensure fire safety in all existing homes. Under the Housing Act 2004, the Housing Health and Safety Rating System (HHSRS) is a risked based tool to help local authorities identify and protect against risks and hazards to health and safety, including that of fire safety. The powers under the Act enable local authorities to take action where necessary. The Home Secretary has a statutory requirement to prepare a Fire and Rescue National Framework for England setting out priorities and objectives for fire and rescue authorities to enable them to effectively discharge their functions . Fire and rescue authorities are expected to work closely with partners in the public and voluntary sector to reduce the risk to vulnerable individuals. As part of their fire safety function , fire and rescue authorities provide home fire safety checks which includes educating individuals on fire safety measures in their homes. During such visits , their officers provide tailored fire prevention and safety advice and may provide and install smoke alarms free of charge. Where risks are identified, which cannot be dealt with by the fire and rescue authority, they work closely with other public services through existing local arrangements - such as multi-agency safeguarding hubs - to ensure appropriate action can be taken to protect vulnerable individuals. In addition to the work carried out by local fire and rescue services, the National Fire Chiefs' Council has published a document called 'Fire Safety in Specialised Housing' available online which provides additional guidance for those assessing risk in specialised forms of housing. This recommends a person-centred risk assessment for vulnerable residents to provide tailored risk mitigation. As well as sprinklers and enhanced fire detection, this includes other established mitigation strategies including provision of ignition resistant bedding and fire-retardant nightwear. I hope this response makes clear the importance the Government places on improving fire safety and our ongoing commitment to ensure people are and feel safe in their own homes. Thank you again for your letter and report. With every good wish, Rt Hon Michael Gove MP Secretary of State for Levelling Up, Housing and Communities and Minister for Intergovernmental Relations
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