Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0271, written 5 May 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 May 2022 |
|---|---|
| Reference | 2022-0271 |
| Deceased | Keith Holmes |
| Coroner | Joanne Lees |
| Coroner area | Black Country |
| Category | 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. P3 Charity Head Office Eagle House, Cotmanhay Road, Ilkeston,
Derbyshire DE7 8HU
1
CORONER
I am Mrs Joanne Lees, Area Coroner for the Black Country.
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
https://www.legislation.gov.uk/uksi/2013/1629/part/7
3
INVESTIGATION and INQUEST
On 21/2/22 I commenced an investigation into the death of Mr Keith Holmes dob 6/11/72
who died aged 49 on 30/12/21. The investigation concluded at the end of the inquest on
4/5/22.
The inquest was heard before myself sitting without a Jury and my conclusion at inquest
was one of Accidental Death.
The medical cause of Mr Holmes death was recorded as
1a) Fatal Asphyxia
1b) Smoke Inhalation (Fire Induced)
At inquest, I made the following findings of fact;
In the early hours of 30/12/21 Fire services responded to a report of a fire at McHugh
House, 89-95 Dickens Road, Wolverhampton. A fire alarm at the property had been
activated and the fire discovered by an on-duty night manager. Firefighters entered
where there was a fully developed fire and Mr Holmes was
discovered unresponsive on the floor under a window with his feet towards a bed.
Smoking materials were observed near the bed. Mr Holmes was removed from the room
and confirmed as deceased at the scene. A post mortem confirmed Mr Holmes died
from smoke inhalation. A Fire Investigation failed to determine whether the fire was
caused by an electrical fault involving a fridge in Mr Holmes room, due to extensive
damage to the fridge, or, by the ignition of Mr Holmes’ clothing or bedding caused by
smoking materials which then transferred burning material closer to the fridge.
4
CIRCUMSTANCES OF THE DEATH
1. Mr Holmes had been residing in
at McHugh House, 89-95 Dickens
Road Wolverhampton since 28/12/21. The property was a house of multiple
occupation leased from Wolverhampton City Council by the Charity known as
P3 (People Potential Possibilities). He had been accommodated at McHugh
House (referred to as the property or Dickens Lodge) as part of the local
authorities winter accommodation provisions as Mr Holmes had become
homeless. He was allocated
.
1
2.
3.
4.
In the early hours of 30/12/21 the night manager at McHugh House was alerted
by an alarm of a fire on the second floor. The fire was originating from within Mr
Holmes’s room and was fully developed by the time fire fighters arrived. Mr
Holmes was found unresponsive in his room and confirmed as deceased shortly
afterwards. A Fire Investigation failed to determine whether the fire was caused
by an electrical fault involving a fridge in Mr Holmes room, due to extensive
damage to the fridge, or, by the ignition of Mr Holmes’ clothing or bedding
caused by smoking materials which then transferred burning material closer to
the fridge.
I heard in evidence that the fridge in room 13 had been supplied by P3 for use
by Mr Holmes in his room. It was reported the fridge has been purchased over 2
years before the incident but the age of the fridge, make and model number was
not recorded. There were no other electrical appliances in the room.
I was told in evidence that P3 had a policy whereby Portable appliance
testing (hereafter referred to as PAT) was carried out by a member of P3
maintenance team on an annual basis.
5. Prior to Mr Holmes moving into
on 28/12/21, the fridge had last been
PAT tested on 17/6/19 and was due to be retested in June 2020. P3 accepted
that the PAT testing was out of date at the time Mr Holmes moved into room 13
on 28/12/21. P3 gave evidence that the Covid restrictions imposed by the UK
Government were such that annual PAT testing could not take place during the
pandemic. The reason why was not fully explained.
I was told that P3 maintenance operatives who would ordinarily undertake the
PAT testing had been placed on furlough in 2020.
6.
7. P3 told me in evidence that the Covid restrictions meant residents were
expected to spend a significant period of each day in their room.
8. P3 told me in evidence that the Charity had not conducted any further risk
assessment in view of there being an increased risk of fire or accident posed by
unmaintained electrical appliances whilst Covid restrictions were in place and
access to the property was limited.
9. P3 told me that despite the Covid restrictions which prevented PAT testing, that
there had been a yearly fire risk assessment carried out on 22/4/21 at the
property which identified the PAT testing as being out of date. No further risk
assessment was conducted, and no other action was taken.
10. P3 told me in evidence that they had a contract with OHEAP Fire and Security
but had not asked for any advice from them with regard to reassessing the risk
posed by the PAT testing not taking place.
11. P3 told me in evidence they had not taken any advice on how to manage the
increased risks from the Fire Service.
12. P3 told me in evidence they had not taken any advice from either the local
authority or any other organisation on how to manage the increased risk of fire
or accident posed by unmaintained electrical appliances presented by the PAT
testing of electrical appliances in McHugh house being out of date.
13. P3 told me in evidence that they were unaware of any guidance issued by the
Health & Safety executive regarding PAT testing during the pandemic (see HSE
Guidance April 2021).
14. P3 did give evidence that the Charity had maintained a system of monthly and
weekly room checks at the property. This included a visual check of electrical
points for any sign of damage. They also told me a visual check was also
undertaken on 21/12/21 and shortly before Mr Holmes moved into
.
15. Most lockdown restrictions in the UK were lifted on 4 July 2020. The fire in Mr
Holmes room occurred on 30/12/21. P3 told me in evidence that furloughed P3
maintenance operatives responsible for PAT testing had only recently returned
to work and that PAT testing had only resumed in McHugh House on 10/1/22.
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 could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
2
The MATTERS OF CONCERN are as follows. –
(1) There was an increased risk of fire or accident due to unmaintained electrical
equipment during the Covid 19 pandemic;
(2) P3 failed to carry out a reassessment of the increased risks posed by the non-
testing of electrical appliances in McHugh House during the Covid 19 Pandemic.
This was during a time when it was expected that residents would spend significant
periods of each day in their room;
(3) I was told in evidence that P3 do not have a contingency plan on managing the
increased risks posed by the absence of PAT testing in the event the UK is placed
into a similar lockdown situation as experienced during 2020/2021.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 4/7/22. 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
. I have also sent it to Wolverhampton City Council as
landlord of the premises who may find it useful or of interest.
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.
9
[DATE]
5/5/22
Area Coroner
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.
Mrs Joanne Lees Area Coroner The Black Country Coroners Court Jack Judge House Halesowen Street Oldbury B69 2AJ Dear Mrs Lees Inquest touching upon the death of Keith Holmes I am writing with reference to the Regulation 28/Prevention of Future Deaths Report dated 5 May 2022 sent to the organisation on 6 May 2022. As a preliminary matter, the organisation would want it noted that the witness who gave evidence, , did so against a background that in addressing the questions asked of her these were felt to be of a technical nature, more directed at a witness with a health and safety background which does not have and hence it is possible that her responses were such that this has given rise to the regulation 28 /PFD report which had someone with a more health and safety background been giving evidence this may not have been necessary. than put forward by the organisation to give evidence. It became apparent on the day of the inquest during questions of scope of expertise and knowledge. Whilst operational background where her focus is on managing the licensees. that these were of a technical nature that were beyond did her best to assist the court this was from an had been summoned by the court rather Further, in discussions post the conclusion of Mr Holmes’ inquest, it has become apparent that the organisation had taken advice from public health authorities about how to manage the situation in the pandemic. Reflecting that advice, the organisation was having to balance obligations to the licensees in their premises and their duties to their employees. The organisation’s maintenance staff had not been put on furlough on account of financial issues because the income streams that the organisation had come from health and local authorities and were therefore largely protected, but because of the practical consequences which was that the nature of the work that the maintenance staff undertook meant that they were coming into contact with licensees and other people increasing the risk of Covid. Reflecting the public health advice that the organisation received, they were told that this was not something that they should be encouraging. As such therefore, the organisation’s maintenance department only undertook urgent maintenance during the pandemic. Turning now to the three matters of concern within the Regulation 28/Prevention of Future Deaths Report, the organisation would respond as follows. P3 PFD RESPONSE LETTER RHL 0622 The organisation has sought advice from OHEAP, the Health and Safety Executive and the Fire Service to ascertain what advice they would given in light of the areas of concern raised. These enquiries were undertaken by the organisation’s Head of Property Services. The Fire Brigade responded to the organisation as follows: ‘During the pandemic and forced isolation periods, we did give advice about various aspects of peoples fire safety arrangements and more specifically, the regularity of maintenance. The underlying theme to all of the advice, was what is the biggest risk to your organisation? Failing to lock down sufficiently and allowing the chance of Coronavirus entering your property was not only illegal, it was probably just as lethal as a fire turned out to be. These risks need to be balanced and decisions made accordingly. The legislation that we enforce, the Regulatory Reform (Fire Safety) Order 2005 looks at risk of death and/serious injury from fire or its effects, and more pertinently any steps taken to make a suitable and sufficient assessment of that risk and address it. It could be argued that you risk assessor made a suitable assessment based on the bigger risk of Covid 19’. Reflecting this advice, the organisation has taken the view that whilst a risk assessment would be undertaken in the future, reflecting the response from the Fire Service above, it is likely that the public health considerations would outweigh the fire risks. As part of the organisation’s response to the Covid pandemic, a risk assessment was undertaken on 17 April 2020 balancing the public health advice and the risks posed to the licensees, visitors and organisations staff. Furthermore, Wolverhampton Safeguarding Together produced guidance dated 30 June 2020. The available guidance that the organisation complied with very much focussed on the risks in relation to Covid that outweighed the risks that may be associated with a fire. The organisation, following coming out of the Covid pandemic, has undertaken PAT tests on 10 January 2022 that did not identify issues with any electrical equipment (including fridges) within McHugh House. As undertakes PAT testing annually, notwithstanding that the regulations would only oblige it to undertake PAT tests once every 4 years on fridges. evidence at the inquest indicated, the organisation ordinarily As the organisation pointed out in its evidence at the inquest, it did through its staff undertake daily inspections of the property. A PAT test is of course only as good as the date on which it is undertaken. As such, in the event that there was to be a similar lockdown situation similar to that experienced during 2020/2021, the organisation would be guided by advice received from several agencies including Public Health England and the Fire and Rescue Service. However, it would have to balance the respective risks that were posed and it seems reflecting advice that the organisation has received from the Fire Service, the balance of that risk, assuming of course the pandemic would be as severe as that experienced in 2020/2021, would appear to rest with public health guidance outweighing risks that may exist in relation to fire. As such whilst the organisation can give a commitment it will have a contingency plan in place, precisely what that plan will look like will be dependent on the advice available to the organisation. As such, the organisation does not feel that at this stage it can produce a contingency plan but it will be guided by relevant advice to be sought at the time to determine its plan on managing any increased risks posed by the absence of PAT testing. P3 PFD RESPONSE LETTER RHL 0622 Yours sincerely Director of Services P3 P3 PFD RESPONSE LETTER RHL 0622
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