Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0302, written 10 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Sep 2021 |
|---|---|
| Reference | 2021-0302 |
| Deceased | Barry Martin |
| Coroner | Christopher Murray |
| Coroner area | Manchester South |
| 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: Jigsaw Homes Tameside, 249 Cavendish Street, Ashton-Under-Lyne, OL6 7AT. 1 CORONER I am Christopher Murray, Assistant 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. 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 30th December 2020 an investigation was opened into the death of Barry Martin. On 25th February 2021 an inquest was opened into the death of Barry Martin who died at The investigation concluded at the end of the inquest which I heard on 15th June 2021. Following a post mortem examination conducted on 30th December 2020 the medical cause of death was confirmed as : Hyde SK14 3EG aged 59 years. 1 (a) Acute left ventricular failure (b) Coronary atherosclerosis with superimposed acute pneumonia By way of conclusion, I recorded a narrative conclusion of Natural Causes contributed to by self-neglect. 1 4 CIRCUMSTANCES OF THE DEATH Barry Martin had recent history of self-neglect, depression and heavy alcohol consumption. After concerns were raised for his welfare, Greater Manchester Police attended the properly and forced entry of on 10th December 2020. He confirmed he was dependant but had no intent to self-harm. The front door through which the police had entered the property was subsequently boarded up. Whilst it is possible there were no other exit routes through external doors he could have climbed through a window. Following further concerns raised by his family, Greater Manchester again on 24th December 2020 and Police attended found Mr Martin deceased. He died from acute heart failure precipitated by an acute pneumonia and bronchitis on a background of moderate coronary artery disease and physical frailty. He had neglected himself and had not been eating properly. 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. – After concerns were raised for his welfare, Mr Martin’s front door to his house was boarded up following a forced entry by Greater Manchester Police on 10th December 2020. There were no other exit routes from the property as there was no key available to Mr Martin to be able to use the rear door being the only other door. I am concerned that if occupied houses have to be boarded up that proper checks are made that there are other alternative safe exit routes for residents. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 5th November 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 2 why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner. I have also sent a copy of my report to Greater Manchester Police 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. 9 Dated: 10th September 2021 Signature: Christopher Murray HM Assistant Coroner, 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.
Dear After Inquest Team, We have now reviewed your request and provide the following information by way or response. Concern Raised: The concern raised within the Coroner's Enquiry into the death of Mr. Martin was as follows: 'After concerns were raised for his welfare, Mr Martin's front door to his house was boarded up following a forced entry by Greater Manchester Police on 10th December 2020. There were no other exit routes from the property as there was no key available to Mr Martin to be able to use the rear door being the only other door. I am concerned that if occupied houses have to be boarded up that proper checks are made that there are other alternative safe exit routes for residents.' Jigsaw Group's Response: We can confirm that on 14th December 2020, a Jigsaw technician attended an emergency call out to board up the front door of the property; following forced entry by the Police on welfare grounds. In such circumstances, our usual process is for technicians to enter the property, call out to see if anyone is in the property, and to check for alternative access/exit routes before boarding up the door. However, when our technician attended on this occasion, he was approached by a neighbour who confirmed that the tenant had been taken to hospital so was not in occupation at the time of the board up. Our technician noted that the property had rear door access and was therefore satisfied that the tenant had alternative access to the property. Our supposition, given the tenant was subsequently found to be in the property when the Police attended on the second occasion, is that the tenant had been able to use the rear door to access the property on his return from hospital. The Group's records confirm that when the tenant had signed up for the property he had been issued with four keys for the front door and four keys for the rear door and we can find no evidence to suggest that the tenant did not have a key for, or access to, the property via the rear door of his property at the time when the front door was boarded up. We trust this provides sufficient clarification / assurance on the concern raised. Kind regards, Assistant Director - Corporate Services (Audit)
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