Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0364, written 29 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Oct 2021 |
|---|---|
| Reference | 2021-0364 |
| Deceased | Lorraine Karat |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Alcohol, drug and medication 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: Prevention of Future Deaths report Lorraine KARAT (died 16.06.21) THIS REPORT IS BEING SENT TO: 1. Group Chief Executive Clarion Housing Group Level 6 6 More London Place Tooley Street London SE1 2DA 1 CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 25 June 2021, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Lorraine Karat, aged 68 years. The investigation concluded at the end of the inquest on 25 October 2021. I determination made at inquest of accidental death. The medical cause of death was: 1a multiple injuries 2 recent alcohol use. 4 CIRCUMSTANCES OF THE DEATH 1 Lorraine Karat fell from a second floor balcony outside her flat, possibly in her sleep. She had been drinking heavily. The balcony parapet was only 36cms high and not contained by any railing. One of her sons had warned her that it was dangerous for her to go out there, but she did sleep on the balcony on warm nights. The housing company from which she rented her flat did not intend the balcony to be used by the resident of the flat. However, there is no evidence that the company ever told her this, and there was no warning sign. There were no bars on the window that she had used to access the balcony, nor were there any window restrictors. 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. Clarion Housing is the company from which Lorraine Karat rented her flat. There are 17 flats in the building, in a complex for the over 55s. All residents have been nominated for occupation by the local authority. Clarion is responsible for the fabric of the building. The property is staffed by a Clarion building manager/concierge who undertakes fire and in reading health & safety checks, and may assist residents correspondence and so forth. There is no restriction on visitors, including children. 1. No evidence was provided at inquest of a risk assessment having been undertaken of Ms Karat’s flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat. 2. I was told by Clarion’s group health, safety and wellbeing manager at inquest, that the building manager did not know that there had been any unauthorised use of the balcony. However, the manager did not enter the flat to check, nor was there any evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy. 3. The balcony was not contained by a railing or other structure to make it safe for use. 2 4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony. 5. I do not know whether this situation is replicated in other Clarion properties. Wikipedia describes Clarion as the largest housing group in the UK, with 350,000 properties across 170 local authorities. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that 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 4 January 2022. 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 following. , sister of Lorraine Karat • • • Care Quality Commission for England • HHJ Thomas Teague QC, Chief Coroner of England & Wales , director of housing mgt, Camden Council I am also under a duty to send a copy of your response to the Chief Coroner 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. 3 9 DATE SIGNED BY SENIOR CORONER 29.10.21 ME Hassell 4
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.
In the Inner North London Coroners Court
Inquest touching the death of Lorraine Karat
Response by Clarion Housing Group to the PFD report issued by HM Senior Coroner M.E.Hassell dated
29.10.2021
The Coroner’s concerns:
1. No evidence provided at the inquest of a risk assessment having been undertaken on Ms
Karat’s flat, most especially including the window that opened over a metre high onto the
balcony, thereby rendering the balcony accessible from within the flat.
Response:
Where CHG become aware of specific risks arising in relation to its tenants then risk assessments
of flats will be carried out following CHG’s internal safeguarding process which may involve other
stakeholders. If concerns are identified by or brought to the attention of CHG then appropriate
steps would be taken on a risk-based approach basis.
2. The building manager did not know of unauthorised use of the balcony and did not enter the
flat to check, nor was there evidence that Ms Karat had actually been told that use of the
balcony was not authorised, still less been asked about this during her tenancy.
Response:
Where Ms Karat lived the flats are the tenants’ private property. There is no right for CHG to enter
a flat on a random basis to check if tenants might be accessing a balcony and absent specific
information reaching CHG there would be no reason to ask a tenant if they were accessing a flat
roof.
To try and avoid the possibility of a similar situation arising at any other facility CHG are running a
process to inform tenants that where there are flat roofs to which access might be possible this is
neither authorised nor a safe activity.
CHG have developed the attached “Flat roof Safety Plan” which sets out the items in hand which
seek to address the Coroner’s concerns. This is a living document and will be reviewed and
updated as information is received.
The attached “Dangers of Flat Roofs – Guidance for our residents” document which is now
available in the tenants’ customer facing website area -
https://www.myclarionhousing.com/repairs-and-maintenance/home-safety and is to be
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displayed in common parts in facilities where relevant flat roofs exist as well as tenants being
provided this information.
This information will be conveyed to new tenants in relevant buildings as part of the tenancy
agreement sign up procedure.
To ensure that staff are aware of the risks arising from unauthorised flat roof access CHG are
issuing guidance to staff as shown in the attached “Dangers of flat roofs – Guidance for
staff”.
This document instructs staff across the CHG sites to identify any flat roofs where unauthorised
access might occur and to engage with the CHG safety team to assess what steps need to be taken
to prevent access being gained to the flat roof.
3. The balcony was not contained by a railing or other structure to make it safe to use.
Response:
CHG did not intend the flat roof to be accessed and used by anyone and were unaware that Ms
Karat was accessing it. If it had been the intention of CHG that the tenant was allowed to access
the flat roof, then appropriate measures would have been taken to provide railings in compliance
with Building Regulations.
The two flats at the facility where Ms Karat was living are no longer occupied and will not now be
used as the facility is in the process of being wound down for eventual closure.
4. There was no sign near the window warning the occupant not to go out onto the balcony and,
most importantly, there were no bars on the window or window restrictors to prevent access
to the balcony.
Response:
As noted in the action plan additional controls are now being deployed where flat roofs have been
identified as posing a significant risk of access from a tenanted property.
Additional measures such as window locks and restrictors can be installed where a risk of
unauthorised access to a flat roof has been identified and a risk assessment indicates that for a
particular tenant that measure should be deployed.
5.
I do not know whether this situation is replicated in other Clarion properties.
Response:
As noted in the Flat Roof action plan CHG are ensuring, by way of engaging Housing Teams
and other key operational teams, that flat roofs with potential unauthorised access are identified
and relevant action taken.
Clarion Housing Group 17 January 2022
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