Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0472, written 23 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Nov 2023 |
|---|---|
| Reference | 2023-0472 |
| Deceased | Kevin O’Hara |
| Coroner | Susan Ridge |
| Coroner area | Surrey |
| 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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Kevin Stephen O’Hara A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ 1 THIS REPORT IS BEING SENT TO: Surrey County Council Executive Director of Adults, Wellbeing and Health Partnerships. Surrey County Council Chief Fire Officer 2 CORONER Ms Susan Ridge, H.M. Assistant Coroner for Surrey 3 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 4 INQUEST An inquest into the death of Kevin Stephen O’HARA was opened on 7 March 2023, resumed on 2 November 2023 and concluded on 22 November 2023. The medical cause of death was: 1a. Inhalation of fire fumes and burns. With respect to where, when and how Mr O’Hara came by his death it was recorded at Box 3 of the Record of Inquest as follows: Kevin Stephen O’Hara died in a fire in the early morning of 7 February 2023 at his home in Frimley, Camberley. He lived on his own and was bedbound in his living room. He was known to smoke in bed and it is more likely than not that the fire started because a lit cigarette fell onto a mattress used as a crash mat next to Mr O’Hara’s bed. This resulted in a smouldering fire which created significant amounts of smoke. Mr O’Hara died from inhaling fire fumes and burns. The fire was only detected when a smoke alarm situated in the hallway of the flat detected smoke seeping through the living room door. Mr O’Hara’s death was recorded at 0420 hours that morning. The inquest concluded with a short form conclusion of ‘Accident’. 5 CIRCUMSTANCES OF THE DEATH Mr O’Hara was aged 63 at his death. He lived in a one bedroom flat on the ground floor of a two storey Independent Living Scheme in Frimley, Surrey. He was bedbound in his living room. He lived alone but carers came in four times a day. He misused alcohol and was known to smoke in bed. Concerns about fire risks from his smoking had been reported to both Surrey Fire and Rescue Service (SFRS), Surrey Adult Social Care (ASC) and the landlords. It was known that he could not self-rescue in the event of fire. Mr O’Hara died in a fire on 7 February 2023 which resulted from a lit cigarette igniting debris on a mattress being used as a crash mat next to his bed. The resulting fire created a significant amount of smoke. The smoke detectors (one linked to a careline operator) and the intercom box were in the hallway. The door to the hallway from the living room was shut. As a result the fire was not detected until sufficient smoke had built up to seep through the top of the living room door into the hallway to then trigger the alarm. Once SFRS became aware that the alarm had activated they deployed quickly but Mr O’Hara died from the effects of the fire before they could reach him. It is not known how long the fire had been burning before the smoke activated the alarm. 6 CORONER’S CONCERNS During the course of the inquest, the court heard that a SFRS Safe and Well Visit conducted on 17 November 2022 did not identify (and as a result did not action) the correct siting of smoke detection/alarm and careline monitor. In the course of the evidence, it was accepted that a visit by ASC to review Mr O’Hara at his flat on 23 January 2023 following concerns about his health and fire risk from smoking should have resulted in a risk assessment. The Inquest heard that SFRS and ASC have undertaken work to mitigate the risks of a recurrence. That work has included, a Serious Incident report, increased training and greater coordination across ASC and SFRS and care providers, updated policy, briefings and the adoption by SFRS and ASC of a new Person at Risk Referral Form to better identify fire risks to individuals. However, 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: Evidence was given that the Safe and Well Visit in November 2022 was conducted by an inexperienced officer. The results of that visit did not seem to be subject to any scrutiny. SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits, with the risk, as in this case, that errors or issues requiring action are not identified. That SFRS reviews of individuals deemed high risk, are usually undertaken by the officer who conducted the initial Safe and Well Visit with the risk that opportunities for oversight and reassessment are missed. Evidence was given that the visit to Mr O’Hara by ASC on 23 January 2023 should have resulted in a risk assessment. Although ASC has policy (some of which predated Mr O’Hara’s death) about when to conduct a risk assessment it does not appear to have in place a system of oversight to ensure that where appropriate, risk assessments follow a visit. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Chief Coroner 2. Mr O’Hara’s family 10 Signed: Susan Ridge H.M Assistant Coroner for Surrey Dated this 23rd day of November 2023
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.
HM Assistant Coroner Ridge HM Coroner’s Court Station Approach Woking Surrey GU22 7AP Woodhatch Place Cockshot Hill Reigate Surrey RH2 8EF 16 January 2024 Dear Assistant Coroner Ridge Following the Inquest touching on the death of Mr Kevin O’Hara, the Coroner issued a Prevention of Future Deaths Report against Surrey County Council (SCC) and Surrey Fire and Rescue Service (SFRS). This joint response to the concerns raised is provided on behalf of both SCC and SFRS. Prior to addressing the concerns raised by the Coroner, both SCC and SFRS wish to acknowledge again how tragic Mr O'Hara's death was. Both organisations wish to reassure the Coroner and Mr O'Hara's family that they fully recognise that mistakes were made and that this has been taken extremely seriously. The remainder of this response does not seek to detract in any way from that fact. The Regulation 28 Report contained the following concerns: Evidence was given that the Safe and Well Visit in November 2022 was conducted by an inexperienced officer. The results of that visit did not seem to be subject to any scrutiny. SFRS do not appear to have in place a system of review or audit by line managers or more experienced staff of completed Safe and Well Visits, with the risk, as in this case, that errors or issues requiring action are not identified. That SFRS reviews of individuals deemed high risk, are usually undertaken by the officer who conducted the initial Safe and Well Visit with the risk that opportunities for oversight and reassessment are missed. Evidence was given that the visit to Mr O’Hara by ASC on 23 January 2023 should have resulted in a risk assessment. Although ASC has policy (some of which predated Mr O’Hara’s death) about when to conduct a risk assessment it does not appear to have in place a system of oversight to ensure that where appropriate, risk assessments follow a visit. Both SCC and SFRS are concerned that the Coroner did not receive all of the pertinent information relating to this concern prior to issuing the PFD Report. SCC/SFRS hope that the below response, which includes an explanation of structures and processes already in place and those which have changed since Mr O’Hara’s passing, sufficiently allays the concerns that she has raised. Surrey County Council The Coroner expressed a concern that: (1) There appeared to be a lack of managerial oversight in relation to the visits by Adult Social Care staff to Mr O’Hara on23 November 2022 and 23 January 2023, and (2) The 23 January 2023 visit was not undertaken by a qualified Occupational Therapist or Social Worker. In relation to the concern regarding managerial oversight, SCC has procedures in place for managerial oversight of such visits, however, the coroner was not provided with evidence of these at the Inquest, SCC apologises for this. Several significant changes have been implemented following the death of Mr O’Hara to ensure robust management oversight following home visits and in relation to decision making around Section 9 assessments is in place and understood by all staff. All new contacts and referrals are screened by both a Practitioner and Manager through the duty front door process, ensuring that decisions taken, and actions required are clearly recorded. Referrals are prioritised based on the information received, risk and urgency. Referrals are allocated to staff based on the level of expertise and competency required of the Practitioner. Managers and Senior Practitioners are required to have oversight of all work to ensure actions are completed in a timely way. New processes have been implemented to the electronic client database to ensure management sign off is required. There is now direct oversight of visits such as those conducted for Mr O’Hara in November 2022 and January 2023. The duty and allocation SOP that was in development in 2023 and referred to at the Inquest is currently being reviewed to ensure that it is fit for purpose moving forward. SCC maintains an audit process as set out in Appendix A. This ensures that assessments are audited to ensure quality in accordance with a robust framework. Once the audit has been completed it will be sent to a Team Manager for review and following this, it is sent to the Senior Manager, adding an additional level of scrutiny and learning. SCC also maintains a Supervision Policy (Appendix B) that mandates that supervision be conducted by a suitably experienced person (paragraph 5.7). In accordance with the policy, in addition to ad hoc supervision (paragraph 7.3), formal supervision takes the form of 1.5 hour protected time on a regular monthly (or six-weekly for part time staff) basis for all frontline staff and 1 hour for non-frontline roles (paragraph 5.8). Both line management and professional supervision may increase in regularity in support of effective performance management complex case management and/or the supervisee’s wellbeing. All staff consider positive risk taking as part of our overall assessment process. However, the training department (‘Surrey Academy’) have been directed to commission specific risk training for all staff to include risk identification and escalations. In May 2023, it was also agreed to add a “potential risk including fire” section to the Manual Handling Assessment to ensure Practitioners such as OTs consider fire risk, particularly when prescribing equipment. The SCC Practice Improvement Board will be established from February 2024 and will have oversight of practice needs and improvements across the whole of ASC. This will be managed by the Principal Social Worker, Principal OT and the Safeguarding Lead and consideration of the risk assessment policy and framework has been confirmed as a priority. In relation to the concern that the practitioner who visited Mr O’Hara in January 2023 was not a qualified Occupational Therapist or Social Worker, SCC employ registered and unregistered staff to carry out their duties under the Care Act 2014. All new members of staff complete a 6- month probation period and induction programme to ensure they are aware of the requirements for their particular role. All staff receive supervision and appropriate training is provided to ensure the workforce is competent. Performance is regularly reviewed, including observational visits. The steps taken to improve managerial oversight will highlight practice and actions required ensuring the necessary assessments are taken by an appropriate practitioner. Surrey Fire and Rescue Service The Coroner expressed a concern that there appeared to be a lack of managerial oversight in relation to the Safe and Well Visit (SWV) conducted on the 17th November 2022. SFRS does not believe that the Coroner was provided with all necessary evidence pertaining to the conduct and oversight of SWVs during the Inquest and it is hoped that the below explanation and evidence sufficiently allays the concerns raised. SFRS apologises that this information was not provided at the Inquest, but it was not clear until the conclusion of the Inquest that the question of staff competence or managerial oversight was a specific concern. A concern was expressed regarding the competence of the staff member who conducted the SWV for Mr O’Hara on 17th November 2022 due to her being a relatively new member of staff. This staff member was a relatively new employee, but SFRS maintain that she had received sufficient training to ensure that she was competent to conduct SWVs. The staff member was employed on 20 April 2022 and received 2 full training days with a Watch Commander before completing shadowing of colleagues for 3-4 weeks before her progress was reviewed on 16 May 2022 and was signed off as competent. All new staff members also complete a New Joiner Programme online. Staff are then monitored continuously for 6 months, and their performance reviewed throughout this time. A performance review was held for this member of staff on the 18th July 2022 which did not raise any concerns. After 6 months the probation period will end unless concerns are raised by the line manager and extension is applied for. Performance Conversations were held with WC Phillip Stonebanks and attendance at an annual mandatory CPD session for all staff, which the staff member attended on the 22nd February 2023. At the time of this staff member’s training, her competency was based on SFRS Policy and Guidance for completing SWV’s. The Community resilience Power Point (Appendix C) is the basis that all staff are trained to along with the training being based on the NFCC Person Centred Framework (Appendix D) and use of the NFCC Competencies to support Home Fire safety Visits (Appendix E). The finalised version of this document was not available at the time of the staff member being trained (draft copies were available), as it was only developed over the course of 2023 and is awaiting final approval, however the approaches referred to in the guidance were already adopted within the Service. Once assessed as competent, SWVs will be carried out by a staff member without being shadowed. However, there is a system of informal support throughout the Community Safety Team and any questions or concerns can be highlighted at any time before, during or after a visit, with assistance being given from the Partnership coordinator or any team member. This is currently an informal process that is not documented in a policy. As a result of the Coroner’s concerns and an His Majesty's Inspectorate of Constabularies and Fire Rescue Services (HMICFRS) inspection, a formal Quality Assurance process is now being developed (see below). In relation specifically to SWVs, staff are provided with comprehensive training (see Appendix F for PowerPoint Presentation). This training was initially developed in August 2020 and at the relevant time was given by Area Commander Andrew Treasure, Station Commander on identifying and mitigating fire risks as part of a SWV. Part of this training specifically and Crew Commander . The training focuses addresses the risks posed by smoking and a resident with mobility issues. The training was amended after Mr O’Hara’s death to include the following: “If the individual is bedbound, it is SFRS procedure to ensure that they have an additional smoke alarm installed in this room” “Telecare systems should be recommended if not already installed in the property. The linked smoke alarm and call points need to be located in the compartment where the occupant is, so that detection and call for help can be accessed easily.” In addition, SFRS produces a Guidance Document (Appendix G), last updated in October 2023, for SWVs which is available in all fire stations in the SWV document and leaflet folders and in Section 24 “All SWV documents” on the SFRS SharePoint Community Tool box. Following Mr O’Hara’s death, a Procedural Alert was issued on 28 February 2023 (Appendix H). This alert was sent to all staff with access to Learning Pool (including volunteers). The alert then sits in the learning pool for continued access and access to this is now checked monthly to confirm who has accessed the alert. The Procedural Alert deals specifically with the learning from Mr O’Hara’s death and has broader relevance to the nature and recommendations of SWVs for immobile residents. SFRS have in place a risk-based points system for SWVs. Staff have received training on how to apply this points system and it is embodied in a new form (Appendix I). This system is aligned to the NFCC guidance on persons at risk from fire and the allocated points that are attached to the answers also align with national guidance. This allows SFRS to see those at most risk across the County and will allow SFRS to follow up with any further visits and liaise closely with other support agencies that may be involved with the individual. If further support and engagement is recommended, SFRS can revisit to try and engage, build relations and make progress on behaviour change to improve safety and mitigate risk. This process will be implemented service wide in 2024 when the new system is embedded in the Service. Quality assurance is currently carried out informally by observation by managers. The manager will speak to the officer who delivers the SWV to ascertain their understanding of what and how they are delivering safety messages. SFRS recognise that there is currently no formal quality assurance system in place that enables formal managerial oversight of the SWV to ensure that services are provided in a consistent and safe way. Whilst SFRS training of its staff has been significant over the last few years, QA is one area that has yet to be implemented. There is an informal process within the small central partnership team to ensure that those conducting SWVs are competent to deliver this service, however a formal process is currently being developed. This area of improvement was also identified by HMICFRS during an inspection in 2023. As a consequence, QA is part of the HMICFRS inspection improvement plan with a project workstream and timeline. This project will be overseen by SFRS governance to ensure that a suitable method of QA is implemented. The timeline is set for January - June 2024. The formal system of QA will involve the partnership team and managers shadowing each fire station team at least once a year to ensure that the delivery of SWV is safe and consistent with expected standards. This will be recorded on SFRS data systems and will result in a “safe to deliver” certificate for that team. The project to implement this will also explore the feasibility of the fire station manager being tasked with a similar process in the interim six months to ensure that crews maintain competence and to take account of any new personnel on that station. SFRS will continue to review incidents and implement new processes or safety systems in a prompt manner, as happened following the death of Mr O'Hara. SFRS fully accept that errors were made during the SWV on 17 November 2022 and that these errors were not picked up through managerial observations. SFRS wish to assure the Coroner and the family of Mr O'Hara that this is fully recognised and that the above steps are being taken to avoid such mistakes in the future. Yours sincerely n Chief Fire Officer Executive Director – Adults, Wellbeing & Health Partnerships
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