Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0401, written 20 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2023 |
|---|---|
| Reference | 2023-0401 |
| Deceased | Jill Brice |
| Coroner | Gareth Jones |
| Coroner area | West Sussex, Brighton and Hove |
| 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: 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: 1 Mr. Michael GOVE MP Secretary of State for Housing 2 Chief Executive Care Quality Commission 1 CORONER I am Gareth JONES, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 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 04 January 2023 I commenced an investigation into the death of Jill BRICE aged 93. The investigation concluded at the end of the inquest on 18 October 2023. The conclusion of the inquest was that: 4 CIRCUMSTANCES OF THE DEATH Jill Brice died on the 23rd of December 2022 at Royal Sussex County Hospital in Brighton. She was in sheltered housing in the Dene (Housing Association property). The extractor fan in her residence , Brighton caught fire causing her to suffer burn injuries and smoke inhalation from which she died. Mrs. Brice was not wearing her emergency pendant when she died. The Fire Safety Report (attached) recommended that care residents be reminded to have their pendant close to them at all times. I would like reassurance that this be actioned. 5 CORONER’S CONCERNS During the course of 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: (brief summary of matters of concern) The Fire Safety Report recommended that care residents be reminded to have their pendant close to them at all times. I would like reassurance that this be actioned. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by December 15, 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 1. 2. East Sussex Fire & Rescue 3. Secretary of State for Health 4. Chief Executive NHS England 5. Teacher Housing Association 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 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: 20/10/2023 Gareth JONES Assistant Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
HM Assistant Coroner Gareth Jones Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk 11 March 2024 Dear HM Assistant Coroner Jones, Response to prevention of future death report following an inquest into the death of Jill Brice Further to the naming of myself as the Chief Executive of the Care Quality Commission (CQC) as a respondent in the Prevention of Future Death report issued following the death of Jill Brice on 23 December 2022, we regret that a formal response has not yet been provided to your office and sincerely apologise for this. I recognise that the initial response was due from us by 5 December 2023 and that an extension of time was requested until 24 January 2024 in my letter to you of 12 January 2024. I would like to further apologise that this response was not provided within the extended timescales that we had anticipated. We note that the concern raised in the Prevention of Future Deaths Report at part 5 are as follows: The Fire Safety Report recommended that care residents be reminded to have their pendant close to them at all times. I would like reassurance that this be actioned. Unfortunately, we are unable to provide reassurance required regarding this concern or to comment upon it. The accommodation where Jill Brice resided was sheltered accommodation managed by the Teachers Housing Association, a not-for-profit charitable organisation. This organisation is not registered with us and therefore not regulated by us. The Teachers Association would not be required to register with us unless it was providing a regulated activity, as defined in section 8 of the Health and Social Care Act 2008 and Part 1 paragraph 2 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We understand that the Teachers Association is an organisation registered with the Homes and Communities Agency as a Registered Provider (registration Number LH0426); affiliated with the National Housing Federation, registered with the Financial Services Authority under the Co-Operative Community Benefit Societies Act 2014 (Registration Number 17955R). Our National Enforcement Team has reviewed the information available and based on that information is of the view that the Teachers Housing Association is not providing a regulated activity and as such does not require registration with us. If you have any further queries, please do not hesitate to contact us further. Yours sincerely, Chief Executive
HM Assistant Coroner Gareth Jones Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA www.cqc.org.uk 12 January 2024 Dear HM Assistant Coroner Jones, Regulation 28 Report following the inquest into the death of Jill Brice Thank you for your Regulation 28 Prevention of Future Deaths. We apologise for the delay in providing our formal response to the Regulation 28 report dated 10 October 2023, which we recognize should have been provided to you by 5 December 2023. Due to a processing error, your Regulation 28 report was not considered for review until 2 January 2024. We take Regulation 28 reports very seriously and value the information contained within them for the purposes of helping inform proper discharge of our regulatory functions. We therefore very much regret the delay that this error has caused. We will seek to address that error at pace with process improvements to ensure that there is no repetition of the issue. We have undertaken a rapid review of the concerns raised in your Regulation 28 report and established that the location where Mrs Brice was residing at the time of her death, namely the Dene, The Green, Rottingdean, Brighton, was not registered with us. We have also reached the provisional view that the location, appears to fall outside the scope of registration with us, and so outside the scope of regulation by us. We have formed that provisional view following analysis of the information in your report, the Record of Inquest, Fire Investigation report and additional enquiries undertaken. Our analysis is that none of the information gathered indicates that registrable regulated activities requiring registration with us, under Schedule 1 of the Health and Social Care Act (Regulated Activities) Regulations 2014 or CQC Scope of Registration, were carried on. However, in order to prepare and provide a considered formal response to your Regulation 28 report, we wish to gather further information to inform a considered and thorough assessment. In those circumstances, we respectfully request: 1. that you grant us interested person status as a sufficiently interested person under section 47(2)(m) of the Coroners Act 2009, and provide disclosure of the coronial bundle pursuant to Rule 13 of the Coroners (Inquests) Rules 2013 (Rule13); and 2. That you grant an extension until 24 January 2024 for submission of our formal response to your Regulation 28 report. Please do not hesitate to contact us with any questions arising. Yours sincerely, Chief Executive
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