Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0086, written 9 Mar 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Mar 2023 |
|---|---|
| Reference | 2023-0086 |
| Deceased | Tomas Ceida |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORTS TO PREVENT FUTURE DEATHS 1. CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction 2. CORONER’S LEGAL POWERS I make these reports under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INQUEST An inquest into the death of Mr Tomas Ceida was opened on 16th August 2016. He had died on 9th August in hospital. The medical cause of death was 1a Burns and inhalation of fire fumes. (case ref: 139095 CIO) London Fire Brigade, Health & Safety Executive and Metropolitan Police Service investigations took place, but were not concluded until 2021. The inquest was concluded on 15th February 2023, heard before a jury with a narrative conclusion delivered. 4. CIRCUMSTANCES OF THE DEATH Construction work was underway on a site being used by the public as a night club. Staff and construction operatives slept overnight on the site on occasions. The jury concluded that the following contributed to the death: Unsuitable composition and state of the acoustic wall Unsafe and inadequately supervised hot works Failure to agree and communicate roles and responsibilities for fire safety on the construction site, leading to inadequate fire alerts and failure to conduct orderly evacuation of the entire site. There were also inadequate fire risk assessments in place, covering Studio 338. This REPORT IS BEING SENT TO: 5. 1. Greenwich, Chief Executive Office, Woolwich Town Hall, Wellington Street, London SE18 6PW Chief Executive of the Royal Borough of 2. Headquarters, 169 Union Street, London SE1 0LL Commissioner of London Fire Brigade, LFB 3. Hill, Walthamstow, Woodford Green IG8 9PF , former director, JHS Contracts (JHS), 93b Oak 4. , Chief Executive, Health & Safety Executive, Redgrave Court, Merton Road, Bootle, L20 7HS; Caxton House, Level 7, Tothill Street, London SW1H 9NA THE CORONER’S MATTER OF CONCERN 6. The following were established as facts, but do not necessarily represent failings: • RLBG Building Control were aware of the composition of the acoustic wall compacted with hay or straw, and its fire risks and did not follow up the non-receipt of a building application after March 2013. • RLBG Planning Division did not notify London Fire Brigade in 2016 when discovered that the wall was not a living wall as envisaged in the planning application. • LFB visited the site in 2014 and the local team attended large night club events on the site, during construction from 2016, but there was no communication with fire enforcement • JHS were initially documented as principal contractor and its subcontractor as site manager in 2016, but either did not create or did not retain documentation of the alleged change of role before the date of the fire, from discussions with the leaseholder of the site, who was the client. • Although steps were taken by JHS to mitigate fire risks through the subsequent management and supervision of hot works, there is no evidence of what steps are taken by JHS individuals now in the building trade in each case to ensure the responsibility for fire safety and evacuation has been competently adopted and implemented. • It is understood that changes in the law and duties of securing general fire precautions has changed since the fire. It is not clear that the public and future contractors are necessarily aware of the processes and duties. The coroner is concerned whether there is a lack of public awareness, which may be a risk to future deaths. This is brought to the attention of the HSE and LFB as enforcement authorities. 7. ACTION SHOULD BE TAKEN The case is brought to the attention of four organizations involved, to enable them to review and report on the individual matters in which they may be able to mitigate further risks and to examine the current collaborative arrangements and ensure they are appropriate and safe. 8. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday May 4th, 2023. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, 9. COPIES and PUBLICATION I have sent a copy of my report to the following other interested persons: for MPS , JHS Insurers Director of Raduga Ltd I am also copying it to The Fire Protection Association, who may have interest in the matter. I am also under a duty to send the Chief Coroner a copy of your response. He 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. 10. [DATE] [SIGNED BY CORONER] 9th March 2023 A N G Harris, Senior Coroner
2 responses 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.
IIIJID
LONDON FIRE BRIGADE
Coroner A N G Harris
Senior Coroner
London Inner South
Southwark Coroners Court
1 Tennis Street
London SE1 IYD
Dear Coroner
Da.e 16 May 2023
Response to Regulation 28: Prevention of Future Deaths Report
I write in response to the Regulation 28 report to prevent future deaths, which you issued following the
inquest touching the death ofTomas Ceida.
London Fire Brigade ('LFB') actions by to address concerns following the inquest
1. Fire safety information about premises attended by LFB inspectors
Since the fire that resulted in the death of Mr Ceida, LFB has brought the role of peak activity inspector
within the mainstream fire safety inspection teams. As such, peak activity inspectors are no longer
independent from other fire safety inspectors.
Existing LFB policy requires that all fire safety officers review premises databases available to them
within the Brigade, in advance of visiting any premises. The Assistant Commissioner for Prevention
and Protection will be circulating a reminder of this requirement to all fire safety inspectors, by e-mail
before 31 May 2023. He also intends to place an article reminding staff of this requirement, in the LFB
fire safety newsletter - Fire Safety News.
Additionally, all frontline appliances carry digital information about non-residential and residential
premises where available, which can include plans, information about building materials, and any
known hazards. Fire Safety Inspecting Officers also have access, via a database, to information about
numerous commercial and residential buildings across London.
LFB is preparing to commence the process of tendering for a specialist contractor to develop a single
point of reference premises risk database, which will enable all information concerning premises to be
centralised and available on demand . All firefighters and fire safety personnel will have access to the
database when it becomes available. This will ensure better preparedness by LFB for all operational
and fire safety contingencies.
2. Public awareness of general fire safety precautions
To meet its obligations under the Fire and Rescue Services Act 2004, LFB has dedicated departments
dealing with community and statutory fire safety matters. These teams continue to actively engage
with local communities to promote fire safety awareness i.e. general fire precautions. The Brigade
conducts fire safety campaigns in the media and will work to ensure that these continue, with the aim
of raising the level of fire safety awareness in the general public.
Following the fire at Grenfell Tower in June 2017, central government introduced the following
legislation aimed at strengthening fire safety in the built environment, including throughout the
construction industry:
Fire Safety Act 2021;
•
•
Fire Safety (England) Regulation 2022;
• Building Safety Act 2022 - in part only)
LFB has enforcement powers under these new statutes, which also serve to promote greater fire safety
awareness across London, with an emphasis on improving the public's understanding of general fire
precautions at premises.
LFB is committed to improving fire safety provisions in premises across London, with the aim of
reducing the number of fires that result in death or serious injury. I hope this response provides you
with the necessary assurance ofthe LFB's commitment to this aim.
London Fire Commissioner
Sent: Thursday, May 4, 2023 1:30 PM Subject: FW: Studio 338 CORONER REG. 28 REPORT Dear Ms Bull, I refer to the attached document and the request from the Coroner to provide a response to the issues raised in Section 6 of the attachment. Please find below the response from the Royal Borough of Greenwich in respect of Planning and Building Control. Studio 338 CORONER REG. 28 REPORT - RESPONSE Building Control Royal Borough of Greenwich takes a proactive approach to enforcement of unauthorised and non- compliant building work. Discoveries of unauthorised and non-compliant work are risk assessed and an appropriate remedy is then determined. Work that is notifiable to Building Control which is started without submission of an application or Building Notice is unauthorised work. If the situation is not dangerous, the owner will be encouraged to regularise the work and bring it into compliance. Should they refuse, or the work is such that it cannot be regularised, then enforcement action will be considered. If low risk, this may be limited to entering the matter on the local land charges register so that it appears on later CON29 searches. Higher risk issues may result in formal enforcement notices being served under section 35 and/or section 36 of the Building Act 1984. If the situation is dangerous, a dangerous structure notice will be served under S62(2) of the London Building Acts (Amendment) Act 1939. All cases are then regularly monitored and the level of required enforcement action reassessed as necessary. Planning Enforcement The Fire Brigade was not notified following the inspection made on 25th July 2016 when it was discovered the sound wall had not been constructed in accordance with the permission granted in 2013 for a living wall with irrigation system but in fact what existed was a wall covered in plastic grass, officers were unaware of the composition as it was not visible to them. Not notifying LFB was not a failing or a disconnect in the service, there is not a statutory or procedural duty to do so. The operator and leaseholder of Studio 338 known as verbally on site on 25th July 2016 that the works to implement a steel frame enclosure were unlawful, must cease and the structure must be removed. This was formalised in writing to the appointed legal representative at the premises was several days later on 9th August 2016. on 3rd August 2016, acknowledged on 4th August, the fire of Raduga Ltd was instructed The first visit made in October 2012 identified an unauthorised sound wall, a subsequent planning application submitted in 2013 applied for a living sound wall with irrigation system, this was approved and as a consequence it was a reasonable assumption that the approved sound wall to have been constructed in accordance. There were no reports or observations made to Planning Enforcement to the contrary from other sources including the Fire brigade, Fire risk assessment surveyors, Metropolitan Police , Licensing Officers, Licensing Police , Environmental Health officers, patrons and members of the public all of whom would have had visual access to the 11 metre high wall covered in artificial grass that existed in those intervening years. The council established an Integrated Enforcement Initiative in 2018 which pulls from all services with enforcement powers, it meets weekly and shares information between internal departments within the council including Licensing , Planning , Building Control , Environmental Health and external partners including the Police and Safer Neighbourhoods Teams and LfB. This information sharing group reviews amongst other things the operational activities of licensed premises such as Studio 338 and inspections made can identify areas of concern which may not otherwise be apparent to officers with relevant powers to regularise. In addition to information cascaded through the mechanisms of Integrated Enforcement , Planning Enforcement are committed to identify where compliance checks are necessary through their investigation processes. Compliance checks will be carried out where repeated non-compliance has been identified and where there is high risk buildings or operations with heavy footfall such as nightclubs or places of worship. Officers are now able to raise concerns relevant to LfB through the Integrated Enforcement initiative. I trust this clarifies matters but please let me know if you require anything further? Kind regards Assistant Director, Planning & Building Control Directorate of Regeneration Enterprise and Skills Royal Borough of Greenwich
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