Prevention of Future Deaths reports · 2023
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 report | 24 Nov 2023 |
|---|---|
| Reference | 2023-0495 |
| Deceased | Jane Bennett |
| Coroner | Neema Sharma |
| Coroner area | Nottingham City and Nottinghamshire |
| 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 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
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.
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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