Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0092, written 16 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 | 16 Mar 2023 |
|---|---|
| Reference | 2023-0092 |
| Deceased | Brian Harfield |
| Coroner | Penelope Schofield |
| Coroner area | West Sussex |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Michael Gove Secretary of State for Levelling up, Housing and Communities 2 Marsham Street London SW1P 4DF 1 CORONER I am Penelope Schofield , Acting Senior Coroner, for the coroner area of West Sussex 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 14th June 2022 I commenced an investigation into the death of Brian George Harfield aged 85. The investigation concluded at the end of the inquest on 3rd March 2023. The overall conclusion of the inquest was a short form conclusion of Misadventure. 4 CIRCUMSTANCES OF THE DEATH On 3rd May 2022 a fire started in the living room of Mr Harfield's flat in the proximity of his recliner chair. It is unclear how the fire started but it was more likely than not caused by the wiring of a lamp which was located close by. Sadly Mr Harfield was overcome by the smoke and was found unconscious in his kitchen. Despite medical intervention by the Fire Brigade he sadly did not recover and was pronounced deceased at the scene. 5 CORONER’S CONCERNS During the investigation, my inquiries 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. The MATTERS OF CONCERN are as follows: The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision. Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of faciites. The providers of such accomodation are not subject to any fire safety provisions. People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in responding to a fire situation and evacuating the residents from the affected areas of the Regulation 28 – After Inquest Document Template Updated 30/07/2021 premises. In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case. We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it. It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities. This is a missed opportunity. The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings - GOV.UK (www.gov.uk) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 10th June 2023 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:- a) The family of Brian Harfield b) West Sussex Fire Service 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 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 by the Chief Coroner. 9 Dated: 16/03/2023 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Penelope SCHOFIELD Senior Coroner for West Sussex Coroners Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
• Department for Levelling Up, Housing & Communities Penelope Schofield Senior Coroner West Sussex Coroners Service Rt Hon Michael Gove MP Secretary of State for Levelling up, Housing and Communities Minister for Intergovernmental Relations 2 Marsham Street London SW1P 4DF ICJJc June 2023 Inquest into the death of Brian George Harfield: Regulation 28 report Thank you for your letter and investigative report (dated 16 March 2023) into the death of Brian George Harfield, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I would like to offer my sincere condolences to Mr Harfield's family and friends. You set out matters of concern and recommended that I, in my capacity as the Secretary of State, should take action to prevent future deaths. You noted a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision. You expressed your concern in terms of an ageing population in which individuals may suffer declining health and mobility and, in similar circumstances, could be overcome by the toxic products of combustion prior to the fire and rescue service being alerted; and that the inquest heard that sprinklers can reduce the amount of smoke produced in a fire and can often extinguish the fire. You also noted that the scope of the sprinklers in care homes, removal of national classes, and staircases in residential buildings consultation did not extend to extra care facilities. That consultation closed on 17 March 2023: https://www.gov. u k/gove rn ment/ co nsu ltations/spri n kle rs-in-ca re-homes-rem ova I-of-national- classes-and-sta i rcases-i n-reside ntia I-bu i Id i ngs/sp ri nkle rs-i n-care-homes-remova l-of-nati ona I- classes-and-staircases-in-residential-buildings The Government recognises that further evidence is required on the benefit of sprinklers and other additional fire protection measures in specialised housing and, to this end, we have a dedicated research workstream in place. I will consider future research findings in light of your concerns and the evidence heard at Mr Harfield's inquest, so that we can consider what changes are necessary to reduce the risk of similar incidents in the future. We have planned future research that will inform us of the benefit of sprinklers over other policy options such as enhancing fire detection and alarms or additional fire compartmentation. This will generate up-to-date evidence to help us review current building regulation policy and inform future changes. Our research work is being phased; stage 1 has already found a body of existing evidence for sprinklers in care homes that enabled us to bring forward evidence-based policy proposals for sprinklers ahead of completion of the research workstream . The scope of the sprinklers in care homes, removal of national classes, and staircases in residential buildings consultation did not extend to extra care premises because, at the time of publication, we did not have evidence for their benefit nor could we have readily defined extra care as there are no statutory definitions for such buildings. We were, however, able to make progress with the consultation setting out proposals for Approved Document B to recommend sprinklers in all new care homes (regardless of height) to be designed to the current British Standard. Stage 2 of the research will generate evidence on the benefit of sprinklers and other fire protection measures, in specialised housing; at present we do not have is present across specialised housing. International robust comparisons are difficult because of variations in overall fire strategy design for buildings. New evidence will inform us of the benefit of sprinklers over other policy options, such as enhancing fire detection and alarm, or additional fire compartmentation . information about where risk Building Regulations: sprinklers in new buildings Building work must meet all relevant requirements of the Building Regulations. The technical requirements are set out in Schedule 1 (section B3) to the Building Regulations 2010, which includes reasonably necessary: inhibiting https://www.legislation.gov.uk/uksi/2010/2214/schedule/1/made the building where the spread of fire within is it Approved Document B provides guidance to meet fire safety requirements set out in the Building Regulations 2010: https://www.gov.uk/governmenUpublications/fire-safety-approved-document-b My department and the new Building Safety Regulator keep guidance in Approved Document B including sprinkler provisions under close review. In 2020, the Government amended Approved Document B to reduce the height threshold (from 30 metres to 11 metres) for the inclusion of sprinklers in blocks of flats; this included extra care buildings designed as blocks of flats . The Building Safety Regulator now has a dedicated workstream to consider what additional fire safety measures may be necessary in specialised housing for vulnerable people, including in extra care facilities. The sprinklers in care homes, removal of national classes, and staircases in residential buildings consultation makes provision for all new care homes to be provided with sprinklers. It was brought forward following stage 1 of our research workstream. Building Safety Regulator officials are reviewing the responses submitted. We will consider where further evidence is required to consider the effectiveness of additional fire protection measures in specialised housing alongside the ongoing research. Sprinklers are only one of a range of potential fire safety measures which may be appropriate to ensure safety. The Building Safety Regulator's review of Approved Document B will look at wider issues and measures as part of the overall fire strategy in these types of building. Sprinklers in existing buildings Fire safety in existing buildings is covered by separate legislation which includes the Regulatory Reform (Fire Safety) Order 2005 (the FSO). The FSO, which is the responsibility of the Home Office, applies to the common parts of multi-occupied residential buildings and requires the responsible person (the person in control of the premises - usually the building owner, landlord or managing agent) to undertake and review regularly a fire risk assessment. The responsible person must then ensure that adequate and appropriate fire precautions that mitigate against the risk to life from fire are in place. It is for the responsible person to determine these measures, based on the fire risk assessment. The Government makes guidance available to support responsible persons in meeting their legal duties under the FSO and they may also seek support from a competent fire risk assessor. The FSO does not apply to individual private homes. Section 6 of the Fire and Rescue Services Act 2004 requires fire and rescue services to promote fire safety in its area, specifically providing information, publicity and encouragement to prevent fire and associated casualties. Fire and rescue services routinely target those most at risk from fire, which included those with mobility difficulties, with in-home person-centred interventions. Home fire safety visits see fire and rescue services visiting homes and providing fire safety advice tailored to the household and living arrangements. This often includes the free provision and installation of smoke alarms but, where the risk is extremely high, it may also include the provision of other fire safety measures such as fire-retardant bedding or smoking aprons. Residents in both new and existing extra care buildings have the right to expect safe, quality, healthy environments and there should be full consideration of the risks in a building to determine the right protection to keep residents safe. My department has taken steps to improve safety for people in privately and socially rented homes . The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022 are now in force and, as of 1 October 2022, all private and social landlords must ensure: at least one smoke alarm is equipped on each storey of their homes where there is a room used as living accommodation; that a carbon monoxide alarm is equipped in any room used as living accommodation which contains a fixed combustion appliance (excluding gas cookers); and ensure smoke alarms and carbon monoxide alarms are repaired or replaced once informed and found that they are faulty. You will also want to know that the Government amended the statutory guidance (Approved Document J) supporting Part J of the Building Regulations to require that carbon monoxide alarms are fitted alongside the installation of fixed combustion appliances of any fuel type (excluding gas cookers) . Fire safety guidance for tenants and landlords and can be found on gov.uk: https://www.gov.uk/government/publications/fire-safety-of-your-building-advice-for-tenants-and- residents/fire-safety-of-your-building-for-tenants-and-residents https://www .gov.uk/government/collections/fire-safety-legislation-guidance-for-those-with-legal- duties In addition, if a local authority inspects residential premises and identifies a fire hazard at the most dangerous 'category 1' level, using the Housing Health and Safety Rating System, it has a duty to take enforcement action under the Housing Act 2004. Landlords must comply with enforcement or can face a financial penalty or prosecution. The presence of a category 1 hazard will also mean the Decent Homes Standard, which all social housing must meet, is failed. Last year, in our Levelling Up White Paper, we committed to halve the number of non-decent rented homes by 2030. In our Private Rented Sector White Paper, we also committed to introduce a Decent Homes Standard to the sector for the first time. Building Safety Regulator Finally, we have introduced a more stringent regulatory regime led by the Building Safety Regulator. The Building Safety Regulator has responsibilities for overseeing the safety of all buildings, including identifying patterns of regulatory failure and making recommendations for improving standards. This will drive continuous improvement in the performance of all buildings to ensure the safety of occupants. I have forwarded your letter to Philip White who has taken up the role of Director of Building Safety at the Building Safety Regulator, pending recruitment of the next Chief Inspector of Buildings. The Government is committed to improving fire safety and to ensuring people are safe and feel safe in their own homes. Thank you once again for providing this report. Rt Hon Michael Gove MP Secretary of State for Levelling Up, Housing & Communities Minister for Intergovernmental Relations
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