Prevention of Future Deaths reports · 2023

Jane Bennett

Regulation 28 report to prevent future deaths, reference 2023-0495, written 24 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Nov 2023
Reference2023-0495
DeceasedJane Bennett
CoronerNeema Sharma
Coroner areaNottingham City and Nottinghamshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation  28: REPORT TO PREVENT FUTURE DEATHS 

REGULATION  28 REPORT  TO  PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 

1 

  Head  of Housing, Mansfield  District  Council 

1  CORONER 

I am Miss Neena Sharma, HM Coroner, for  the  coroner  area of Nottingham City and 
Nottinghamshire 

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 

On  23rd  August  2023, I  commenced  an  investigation into the death  of Jane  BENNETT,  aged 
52.  Mrs.  Bennett  died  on 8th  June  2023  at Kings  Mill Hospital, Mansfield  Road, Sutton-in-
Ashfield, Nottinghamshire, NG17  4JL. 

A post mortem  examination was undertaken by 
Nottinghamshire. In a  report  dated  8th  August  2023, she  gave the  cause of death as  1a  Acute 
exacerbation of non-specific interstitial pneumonitis. 

, at  the  instruction of  HMC for 

In her  comments  to  the  Coroner  she  said: “In  the  view  of history and  autopsy findings in  my 
opinion death  was due  to acute  infective  exacerbation  of  interstitial  lung  disease. Mould  in  her 
house  could  have  contributed  for the  development  of interstitial  lung disease.” 

4  CIRCUMSTANCES OF THE  DEATH 

Mrs.  Bennett  lived  in a  house  provided  by Mansfield District  Council  from  October  2022  until 
her  final  admission  to  hospital in late May 23. She  identified  severe  mould in  her property. 
Photographs  are  attached. 

Mrs  Bennett  had a  diagnosis  of interstitial pneumonitis made  on  CT  scan  01/04/23  and  she 
then had  frequent  admissions to hospital with  worsening respiratory  function in April  and  May 
2023. 

Mrs  Bennett  was admitted to  ITU for  the second time on  28/05/23  with  type  1  respiratory 
failure  requiring  high  flow nasal  oxygen/NIV, high  dose  IV  steroids, antifungals and  antibiotics 
throughout  her  admission. She  failed  to  respond to medical  management  , and  sadly died  on 
8.6.23. 

The  cause  of  her  interstitial  pneumonitis  is not  clear  at  this stage, but  both the  Pathologist 
and the  Respiratory  Consultant, 
  in  his report to  the  Coroner  dated  26.9.23 
(report  attached)  are  clear that  the  mould may be  causal  or  contributory  to  her  death. This 
will  be further  explored  at a  forthcoming  Inquest, date to  be  finalised. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
  
 
 
 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: 

I am concerned that  mould  in  Mrs. Bennett’s  property  and  other  properties  in that area 
owned  and  maintained  by Mansfield District Council may pose  a risk that  future  deaths  could 
occur.  I ask for  the  aforesaid  properties to  be inspected  for  mould  and action  be  taken  to 
ensure  any further  exposure  to  mould  by any tenant is minimised. 

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 19th  January  2024.  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:  -

Family of  Jane  Bennett 
 
  Mansfield  District Council 

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: 24th  November 2024 

HM  Coroner 
Nottingham City  and Nottinghamshire 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Mansfield District Council (PDF)
Mansfield District Council 

Date:  18 January 2024 

Miss Neena Sharma, SENIOR 
CORONER 

HM Coroner 
Nottingham and Nottinghamshire 

The Council House 

Old Market Square 

Nottingham, NG1 2DT 

Dear Miss Sharma 

Re: Jane BENNETT - DOB: 19/09/1970- DECEASED. Late of 23 Eather Avenue 
Mansfield Woodhouse, Mansfield, Nottinghamshire, NG19 8AY 

I  refer  to  your  recent  Regulation  28  Report  to  Prevent  Future  Deaths  dated  24 
November 2023 in respect of Mrs Jane Bennett’s tragic death. 

Firstly, I would like once again to express my deepest condolences, and those of the 
council, to the family of Mrs Bennett. 

This  response  seeks  to  provide  the  Coroner  with  assurance  that  Mansfield  District 
Council  takes  its  role  as  landlord  and  the  health  and  wellbeing  of  our  tenants 
extremely seriously. 

The  Regulation  28  report  details  the  matters  of  concern  being  that  mould  in  Mrs. 
Bennett’s  property  and  other  properties  in  that  area  owned  and  maintained  by 
Mansfield District Council may pose a risk that future deaths could occur. You asked 
for the aforesaid properties to be inspected for mould and action be taken to ensure 
any further exposure to mould by any tenant is minimised. 

This  letter  seeks  to  provide  you  with  certainty  that  the  council  has  responded  to  your 
request  to  inspect  such  properties  and  to  take  action  to  prevent  any further  exposure  to 
mould by any tenant. 

Where  reference  is  made  to  the  contents  of  the  report  titled  ‘SFH  statement  of 

,  Consultant  in  Respiratory  Medicine’,  it  should  be  made  clear  that  the 

council does not have the direct knowledge to verify such references. 

In  response  to  this  request,  please  find  below  additional  information  along  with 
supporting appendices. 

Civic Centre, Chesterfield Road South, Mansfield, NG19 7BH 

www.mansfield.gov.uk 

T 01623 463463  E mdc@mansfield.gov.uk 

MyMansfieldUK 

@MDC_News 

 
 
 
 
 
 
 
 
 
 
 
 
 
     
     
 
 
   
 
         
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  Background and timeline of events, including Mrs Bennett’s reports of mould and 

update on Regulation 28 request to inspect homes. 

A  timeline  of  events  is  attached  to  this  letter  at  Appendix  1.  This  includes  details 
relating  to  Mrs  Bennett’s  tenancy,  any  repairs  service  requests  and  subsequent 
remedial action. A series of photos linked to this timeline of events are also attached 
and  are  labelled  as  Appendix  1  photos  1a-1b,  Appendix  1  photos  1c-1m  and 
Appendix 5 photos 5a-5q. 

Summarising  the  timeline  of  events  at  Appendix  1,  the  council  responded  to, 
investigated  and  successfully  completed,  all  repairs  requests,  including  those 
relating  to  dampness  and  mould,  in  full  accordance  with  the  target  timescales  as 
operated for the Repairs Service and set out within the council’s Repairs Policy.  The 
council  responded  to  Mrs  Bennett’s  requests  relating  to  mould  specifically  and 
inspected  giving  consideration  to  known  health  conditions  and  vulnerabilities  (which 
included  COPD).  The  council  took  proactive  action  to  identify  any  wider  sources  of 
any dampness and took proactive action to treat any mould. 

Mould  growth  was  isolated  to  inside  the  tenant’s  set  of  bedroom  drawers  and 
wardrobe on inspection. Mould growth was not identified in other locations within Mrs 
Bennett’s home. 

However,  a  zero  tolerance  approach  was  taken  to  mould  and  proactive  mould 
treatment  was  undertaken  as  a  preventative  measure  in  the  home  to  minimise  any 
risk  to  Mrs  Bennett’s  health  and  wellbeing.  Mrs  Bennett  was  also  provided  with 
advice  and  guidance  throughout  her  tenancy  to  support  her  to  manage  moisture 
levels. 

Mrs  Bennett  had  not  made  any  complaints  to  the  council  under  the  council’s 
complaints policy throughout the tenancy period. 

The  Coroner’s  Regulation  28  document  received  by  the  council  included  the 
following appendices: 

  Appendix 2 includes photographs taken by Mrs Bennett on 3rd  and 4th  January 
2023  received  from  the  Coroner  along  with  the  above  Regulation  28 
document on 24th  November 2023. 

  Appendix  3 

includes  SFH  Statement  of 

in 
Respiratory  Medicine  received  from  the  Coroner  on  24th  November  2023 
along with the Regulation 28 document. 

  Consultant 

In response to the request for the council to inspect properties in that area for mould, 
the  council  wrote  to  tenants  accordingly.  Appendix  4  details  the  letter  dated  14 
December  2023  sent  by  first  class  post  by  the  council  to  council  tenants  living  on 
Eather  Avenue,  Slant  Lane  and  certain  homes  on  Park  Road  advising  that  the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 council  wished  to  inspect  their  homes  for  mould.  A  total  of  64  tenants  received  this 
information.  These  addresses  were 
letter  along  with  accompanying  advisory 
contacted  as  they  are  the  same  building  archetype  in  the  immediate  area  of  23 
Eather Avenue. 

Prior  to  this  letter  being  sent,  the  council  had  1  ongoing  dampness  request  in  that 
area  which  was  actively  being  remedied.  Following  receipt  of  the  letter,  the  council 
received  contact  from  13  tenants  and  inspections  of  each  home  have  been 
organised  in agreement  with  the tenant.  To date, 41 homes have been  inspected in 
total, mostly after the Christmas period, by a dedicated inspector. 

Of  the  homes  inspected,  mould  growth  has  been  identified  in  15  homes  and  in  all 
cases, mould growth has been minimal. In all cases where mould has been identified 
however, mould treatment will be completed in agreement with  the tenant  within the 
council’s repairs target timescales. Mould treatment  works have started  on site by  a 
specialist mould treatment company. All 64 tenants have received detailed advice to 
support them to minimise moisture levels and reduce the risk of mould in the future. 
A second reminder letter will be sent week beginning 22 January 23 to those tenants 
that  have  not  yet  contacted  the  council  with  the  aim  of  completing  all  remaining 
inspections by 16 February 23.  This programme is dependent upon tenants allowing 
access. 

Whilst  inspecting  their  homes,  the  council  has  also  proactively  noted  any  other 
repairs required, regardless of whether or not they relate to any dampness or mould 
growth. 

2.  Action  taken  to  understand  and  act  on  the  specific  needs  and  vulnerabilities  of 

Mrs Bennett in order to minimise the risks from mould exposure. 

In  summary,  the  council  gathered  information  from  Mrs  Bennett  at  the  outset  and 
throughout  her  tenancy  and  responded  to  all  repairs  requests,  including  those 
relating  to  dampness  and  mould,  in  full  accordance  with  the  target  timescales  as 
operated for the Repairs Service and set out within the council’s Repairs Policy. The 
council  responded  to  Mrs  Bennett’s  requests  relating  to  mould  specifically  and 
inspected  giving  consideration  to  known  health  conditions  and  vulnerabilities.  The 
council took proactive action to identify any wider sources of any dampness and took 
proactive action to treat any mould. 

Mould  growth  was  isolated  to  inside  the  tenant’s  set  of  bedroom  drawers  and 
wardrobe on inspection. Mould growth was not identified in other locations within Mrs 
Bennett’s home. 

However,  a  zero  tolerance  approach  was  taken  to  mould  and  proactive  mould 
treatment  was  undertaken  in  the  home to  minimise  any risk  to  Mrs Bennett’s  health 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and  wellbeing.  Mrs Bennett was also provided  with  advice and guidance  throughout 
her tenancy to support her to manage moisture levels. 

With  reference  to  the  Sherwood  Forest  Hospital  (SFH)  statement  of  Dr  Hutchinson, 
Consultant  in  Respiratory  Medicine  (Appendix  3),  on 
June  2023  a  consultant 
advises  they  were  shown  photos  of  mould  on  the  walls  of  Mrs  Bennett’s  home. 
These  photos  have  not  been  included  within  the  SFH  report  and  therefore  the 
council  are  unable  to  comment  on  this.  However,  the  photos  provided  by  Mrs 
Bennett dated the 3rd  and 4th  of January 2023 (Appendix 2) that have been provided 
to  the  council  by  the  Coroner  appear  to  show  mould  on  Mrs  Bennett’s  drawers  and 
wardrobe only and not on any walls. 

5th 

At  no  point  were  the  council  advised  of  Mrs  Bennett’s  respiratory-related  health 
conditions by the NHS (Sherwood Forest Hospital Trust or her GP) during the period 
of  hospital  admissions  from  March  2023  to  June  2023.  It  should  be  noted  however 
that all proactive repairs and mould treatment was completed well in advance of this 
date on 11th  January 2023. 

The  report  concludes  the  cause  of  Mrs  Bennett’s  Interstitial  Lund  Disease  (ILD) 
remains unclear. Blood tests which might support exposure to fungus were negative. 
Causes of ILD remained unclear and inconclusive. Possible causes included vaping, 
the  medications  Mrs  Bennett  was  taking  as  well  as  possible  mould  (based  on  the 
photos the consultants were shown by Mrs Bennett). The report does not distinguish 
 advises he did not see the mould himself 
between these three factors. 
and  therefore  it  is  difficult  for  him  to  give  an  opinion  on  the  balance  of  probabilities 
whether it did in fact contribute. 

The council’s Customer Services team receive repairs requests on behalf of Housing 
Repairs  and  also  have  the  ability  to  book  inspections  whilst  on  the  telephone  with 
tenants.  When  taking  enquiries  the  service  will  triage  and  identify  whether  a  tenant 
has any additional needs and vulnerabilities. In addition, any information provided as 
part of the allocations and sign-up process will be collected. 

In the case of Mrs Bennett, the council’s housing management/allocations team had 
recorded  a  number  of  matters  relating  to  her  health  and  wellbeing  at  the  tenancy 
outset  including  difficulty  in  walking,  anxiety,  depression,  fibromyalgia  and  mental 
health.  Respiratory  related  health  conditions  were  not  declared  by  Mrs  Bennett  at 
this stage. 

Customer  Services  later  noted  that  the  health  condition  Chronic  Obstructive 
Pulmonary Disease  (COPD) was  self-declared  by  Mrs  Bennett  on  a  repairs  request 
raised on 26 October 2022 regarding a leaking roof affecting the bedroom ceiling. An 
inspection was subsequently arranged at the time of the report for 3 November 2022. 
The  inspection  of  Mrs  Bennett’s  home  took  place  as  arranged  as  soon  as  possible 
on  the  3  November  2022,  6  working  days/8  calendar  days  from  her  initial  request. 
Photos of Mrs Bennett’s home during this inspection are detailed in Appendix 1a-b. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 As a result of this inspection, the source of the reported penetrating dampness in the 
bedroom was identified and an order for an external roofing contractor was raised on 
15  November  2022.  The  roofing  works  were  completed  on  20  January  2023.  The 
inspector  also  provided  advice  and  guidance  on  minimising  condensation  build  up 
within  the  bathroom  and  home  generally.  In  the  meantime,  other  repairs  requested 
were also responded to in a timely manner as detailed in the timeline at Appendix 1. 

With  regard  to  dampness  and  mould  specifically,  a  later  inspection  took  place  on  5 
January 2023, 15 calendar days (including Christmas and New Year Bank Holidays) 
after Mrs Bennett  self-reported damp in her kitchen.  Photos of  Mrs Bennett’s home 
during this inspection are detailed in Appendix 1c-1m. 

An  inspection  took  place  of  the  entire  home  and,  on  inspection,  mould  growth  was 
evident  inside  the  tenant’s  wardrobe  and  chest  of  drawers  in  the  bedroom  (as  seen 
in  the  photos  in  Appendix  1c-1m).  Mould  was  not  identified  on  the  bedroom  walls 
however  or in the kitchen as  reported.  It  was  also  noted  that  the  bed  and bed  head 
was  situated  directly  in  front  of  the  radiator  in  the  bedroom  thus  limiting  the 
circulation of warm air in the room. Mrs Bennett was advised to move the bed away 
from the radiator where possible to maximise the circulation of warm air. 

Whilst in no way seeking to attribute ‘blame’ to the tenant, it was also noted that the 
tenant  was  using an unvented tumble dryer within  the property (within the  outhouse 
as  detailed  in  photos  in  Appendix  1c-1m)  and  advice  and  guidance  was  therefore 
provided  that  this  would  significantly  increase  the  amount  of  moisture  entering  her 
home and thus contributing to condensation. Further advice was provided to support 
Mrs Bennett around how to control moisture levels along with heating and ventilating 
the bungalow. 

In addition to this advice to the tenant, as a result of this inspection, the council also 
took further proactive action as a responsible landlord to minimize the further risk of 
mould  by  replacing  existing  extractor  workings,  installation  of  additional  passifying 
vents in the bedroom and lounge and  immediate  arrangements  were made  to  wash 
down  and  treat  the  bedroom  wall  as  a  preventative  and  proactive  measure.  Mould 
treatment  was  subsequently  completed  on  11  January  2023,  6  calendar  days/4 
working days after the inspection. 

3.  Information  on  the  condition  of  the  property  and  its  compliance  with  the  Decent 

Homes Standard. 

The council commissioned Savills to complete a 30% physical stock condition survey 
late  2021  with  inspections  taking  place  late  2021  to  the  Spring  of  2022.  23  Eather 
Avenue  was  included  within  the  Savills  survey  schedule  and  was  inspected  on  6 
December 2021. The property was deemed decent and no category 1 hazards were 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 identified  as  a  result  of  the  decency  assessment/survey.  The  survey  notes  did  not 
indicate  the  presence  of  mould  or  a  lack  of  other  key  features  such  as  electrical 
ventilation. 

The stock condition survey included 11 other homes on Eather Avenue and 3 homes 
on Slant Lane of this archetype, each of which was assessed as decent and without 
any identified category 1 hazards at the time of the survey. 

Prior  to  Mrs  Bennett’s  tenancy  start  date,  the  property  underwent  various  works 
during the void period including: 

Internal repairs and cleaning 

 
  Electrical safety check 
  Gas safety commissioning 
  Smoke detector check 
  Garden/external works 

The property met the decent homes standard at the point at which the property was 
re-let to Mrs Bennett and achieved a Band C Energy Performance Certificate (EPC) 
rating. 

Photos of the property at the end of Mrs Bennett’s tenancy after her tragic death are 
included at Appendix 5 (photos 5a to 5q) and show no mould growth. 

4.  How risks of mould exposure to other council tenants are being minimised. 

In terms of responding to the Coroner’s Regulation 28 document relating to the area 
of  homes  near  Eather  Avenue,  the  council  wrote  to  64  homes  dated  14  December 
2023  as  detailed  in  section  1.  A  dedicated  inspector  has  completed  home 
inspections  along  with  the  provision  of  tailored  advice  to  tenants.  Whilst  at  the 
tenant’s  home,  the  inspector  has  proactively  identified  any  wider  sources  of 
dampness, if present, along with any other non-damp/mould related repairs. 

In  terms of the  wider housing stock,  further details  regarding the  council’s  approach 
to  minimising  the  risk  of  mould  exposure  to  other  tenants  is  detailed  in  section  5b 
below. 

5.  The council’s overall approach to: 

a)  decent homes compliance; 

The  council  owns  retained  housing  stock  of  6326  homes,  including  10  sheltered 
housing schemes. Our approach to safety and decency is a priority focus. In terms of 
stock  quality  and  our  understanding  of  this,  the  council  commissioned  Savills  to 
undertake  a  30%  stock  condition  survey  during  2021  with  inspections  taking  place 
late 2021 to the Spring of 2022. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 This  data  has  helped  shape  the  direction  and  investment  profile  of  our  homes  over 
the short, medium and longer term. This work combined has resulted in a significant 
increase  in  sustainable  capital  investment  in  council  homes  as  part  of  the  medium 
term  financial  strategy.  Increased  financial  resource  and  capacity  in  this  area  also 
contributes  to  the  council’s  approach  to  addressing  the  root  causes  of  damp  and 
mould via  windows, doors, roofing, heating and electrical upgrade programmes. 

As well as responsive day to day repairs, the Housing service delivers major capital 
including  roofing,  windows,  doors,  electrical 
improvement  work  to  its  homes 
upgrades,  heating  upgrades,  sheltered  scheme  refurbishment,  fire  safety  work  etc. 
The total capital budget for 24/25 totals circa £17,000,000 to facilitate the renewal of 
key  building  components  following  a  stock  condition  survey  with  significant 
investment continuing in future years. 

The  council  has  also  taken  part  in  the  social housing  decarbonisation  demonstrator 
project  as well  as a  domestic  retrofit  project within  the  D2N2  devolution  programme 
with a view to improving the thermal efficiency of council homes. 

The  void  (empty)  period  is  also  used  as  an  opportunity  to  bring  homes  up  to  the 
decent  homes  standard  in  its  entirety  where,  for  example,  tenants  have  refused 
access previously. 

b)  tackling damp and mould. 

We have adopted a triangulated approach to assessing and appraising the extent of 
damp, condensation and mould growth in council homes including: 

 

Independent stock condition surveys as mentioned in 5a above. 

  Early,  proactive  action.  Inspectors  identify  the  root  cause  of  damp  and 
mould  at  the  earliest  opportunity  with  the  support  of  a  range  of  trained 
operatives  attending 
to  qualified 
professionals  as  required.  All  operatives  have  received  both  Housing  Health 
and Safety Rating (HHSRS) training appropriate to their roles as well as damp 
and mould training. Training to utilise dampness measurement equipment has 
also been completed. 

treat  any  mould  with  escalation 

to 

  Colleague  and  Stakeholder  awareness  - Expanded  knowledge  and 
awareness  of  other  colleagues  and  contractors  to  ‘don’t  walk  by’,  reporting 
any instances of damp, condensation and mould growth. 

This  triangulated  model  enables  us  to  regularly  understand  and  evaluate  property 
condition  to  revise  our  approach  to  planned  investment  and  cyclical  maintenance, 
and to monitor delivery performance. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Our  approach  to  remedying  issues  concerning  damp,  condensation  and  mould 
growth focusses on; 

  Upon tenant contacting us, we schedule either a trained Operative or external 
specialist  Contractor  to  attend  to  treat  and  remove  any  reported  instances  of 
mould growth, and prevent the worsening of condition. 

  Within  this  visit  we  triage  the  root  cause  of  damp,  undertaking  any  proactive 
repairs,  scheduling  follow-on  works  or  arranging  technical  inspections  by 
specialist Inspectors or Building Surveyors as required. 

Other proactive actions include; 

  Cross-teams  training  to  improve  awareness  of  the  risks  of  damp  and  mould 
growth  and  to  ensure  stakeholders  can  alert  the  team  to  instances  of,  and 
resolve any damp and mould growth cases. 

  We co-produced guidance information and support for tenants to help identify 
instances of damp, mould and condensation and help to reduce high levels of 
internal moisture in properties. 

  Ongoing  damp  and  mould  social  media  campaign  that  has  been  running  on 
council  social  media  accounts  since  November  2023.  In  total  the  campaign 
has  reached  85,778  people  on  Facebook  and  a  further  3,815  on  X  (formerly 
Twitter). 

  Guidance  information  has  also  taken  the  form  of  physical  leaflets  that  are 
provided  in  tenancy  start-up  packs  and  during  property  inspections  by  the 
repairs team as well as Housing Officers and Community Safety officers. 

  The Summer 2023 Housing Contact magazine delivered to a tenants featured 
detailed  advice  on  damp,  condensation  and  mould  growth  and  how  to  seek 
help as well as other means of support. 

  The  council’s Housing web pages feature a range of advice and guidance on 
links  to  other  useful  sources  of 
damp,  mould  and  condensation  with 
information  around  welfare  benefits,  affordable  warmth,  food  clubs,  priority 
registers and the council’s ASSIST support team. 

  Proactive  working  and  established  links  with  health,  public  health  and  social 
care  (including  safeguarding  teams)  and  education  providers  to  support 
identification and resolution of  damp, condensation and  mould growth  factors 
found in tenant’s homes, and encouraging instances to be reported for prompt 
action.  The  undertook  a  ‘Preventing  Family  Homeless’  pilot  with  Children’s 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 social  care  to  raise  awareness  between  Housing  and  Care  teams  around 
housing-related  issues  including  property  condition  and  created  fast-track 
referral pathways for issues such as damp and mould. 

  The  council  is currently  developing  a pilot  project  in  Mansfield  with  Mid-Notts 
Place  Based  Partnership  and  health  partners  to  train  social  prescribers  in 
housing matters, including damp and mould growth, with specific emphasis on 
families with children experiencing respiratory conditions. 

  Provision  of  a  Mansfield  ‘Healthy  Homes  Hub’  (See  Appendix  6)  to  support 
the most vulnerable tenants and residents to stay safe in their home. Support 
with  property condition,  including  damp,  mould  and condensation,  is included 
within the hub model. 

  Provision  of  an  ASSIST  Hospital  Discharge  service  in  partnership  with 
Sherwood  Forest  Hospital  Trust  and  the  Integrated  Care  System  (See 
Appendix  7)  to  support  discharge  cases  requiring  housing-related  support 
(which  can 
include  property  conditions  such  as  damp,  mould  and 
condensation matters) and prevent admission through work in the community. 

  Working  with  external  contractors  to  ensure  early  warning  ‘on  the  ground’  of 
damp and mould growth in properties enabling us to proactively respond and 
prevent any further property damage and tenant risk. 

  The  council  have  commissioned  an  independent  consultant  from  Savills  to 

review the council’s approach to damp and mould. 

 

Introduced  an  interim  procedure  that  considers  the  potential  timescales  and 
actions  suggested  in the  consultation document  - Awaab’s  Law:  Consultation 
on timescales for repairs in the social rented sector. 

 

Introduced a triage system with scripted prompts for all reported damp, mould 
and condensation cases reported by the tenant. 

  Updated  our  website  to  provide  further  guidance  on  damp,  mould  and 

condensation including tips to reduce moisture in the home. 

  Ongoing 

frequent  performance  management  meetings  with  contractors 
dealing  with  damp  and  mould  treatment  to  monitor  progress  and  ensure 
properties are prioritised where there are occupants that could be significantly 
affected by damp and mould due to medical conditions. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Trialling environmental monitoring devices for placement in tenant’s homes to 

assist with supporting tenants that report damp, mould or condensation. 

 

 

Increased  the  capacity  of  the  inspection  team  responsible  for  visiting  homes 
and investigating reports of damp, mould and condensation. 

Increase the capacity of contractors, both local and framework contractors, to 
support  with  damp  works  and  mould  treatments  to  ensure  a  prioritised  and 
timely response to damp and mould treatment. 

  Procured  mould  kits  from  specialist  mould  treatment  company  for  tenant 

usage to support tenants to prevent mould growth where appropriate. 

  Planned  councillor  workshop  focussing  on  damp,  mould  and  condensation  to 

assist members to provide advice and signposting to constituents. 

I  trust  this  satisfies  your  request  and  assures  the  Coroner  that  the  council  does 
indeed  take  its  role  as  landlord  and  tenant  health  and  wellbeing  very  seriously. 
However  if  you  require  any  further  information  please  do  not  hesitate  to  contact  us 
and we will of course assist as soon as possible. 

Yours sincerely 

Head of Housing

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