Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0173, written 27 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Mar 2024 |
|---|---|
| Reference | 2024-0173 |
| Deceased | Saffra Winn |
| Coroner | Alexandra Poutney |
| Coroner area | South Yorkshire (West) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Sheffield City Council 1 CORONER I am Alexandra Pountney, assistant coroner, for the coroner area of South Yorkshire (West District) 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 29 September 2022 an investigation was commenced into the death of Saffra Harriett Winn. An inquest started on 18 March and concluded on 19 March 2024. The cause of death was: 1 (a) Multiple injuries 1 (b) Fall from height 4 CIRCUMSTANCES OF THE DEATH At approximately 5.55am on 24 July 2022, Saffra was found on the pavement between two blocks of high-rise flats, known as Martin and Burlington. Emergency services were called, and police and paramedics attended the scene. On arrival, paramedics notes that Saffra was unconscious, was not breathing and had suffered extensive injuries that were beyond medical assistance and were incompatible with life. Life was declared extinct by paramedics at 6.08am. The police conducted an investigation, and saw that the window of Saffra’s , was open above the area where she was found. The flat, 1 police concluded that it was likely that Saffra had jumped or fallen from the window of her conclusion for the following reasons: . The police came to that flat a. CCTV was reviewed from the flats which showed Saffra falling from the building and showed that no person had entered or exited her flat during the relevant times. b. The flat door was locked from the inside, with the key in the lock. c. There were foot/scuff marks on the internal and external window sills. There was no evidence of an intention by Saffra to take her own life. The council did not conduct a post-incident safety inspection of the windows in the flat, beyond the usual post-tenancy inspection. The police found that the safety restrictor on the window had been manually disengaged to allow it to open fully. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death. More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 22 May 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 Interested Persons. 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 other 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. 9 Alexandra Pountney HMAC 27/03/2024 3
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.
Neighbourhoods Directorate – Head of Investment & Estates Sheffield Town Hall Sheffield S1 2HH 21st May 2024 Alexandra Pountney HM Coroner Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Ms Pountney, I write in my capacity as Head of Service, Investment & Estates, at Sheffield City Council in response to your Regulation 28 report. In your report you highlighted two areas of concern, which I respond to below: 1 The inquest heard that there have been two fatalities by tenants falling from this type of window in high-rise buildings in a short period of time between July 2022 and December 2023. Notwithstanding these fatal events, Sheffield City Council has not yet completed any risk assessment of the windows or the safety latches on the windows. A Building Safety Regulator was put in post at the council in January 2023, some 11 months before the second fatality and 6 months after the first, and this person has not been consulted in relation to the safety or risk posed by the windows. I am concerned that this poses a risk of future death. The Building Safety Regulator (BRS) was established in January 2023 under the Building Safety Act 2022 and is part of the Health and Safety Executive (HSE). The BRS is a national role and there is no internal role of Building Safety Regulator within Sheffield City Council (SCC). In respect of current guidance or best practice with regards the fitting of fixed window restrictors within high rise accommodations, SCC wrote to the BSR on 18th March 2024. The response from the BSR was received on 28th March 2024 and can be seen below. I am responding to your enquiry relating to the installation of window restrictors either fixed or detachable. My advice is framed in the context of window restrictors being used to demonstrate compliance with building regulations as opposed to being installed to mitigate an identified hazard. The building regulations provide legal requirements to regulate buildings with the intention of protecting the safety, health, and welfare of people in and around buildings. They also set standards for accessibility, water use, energy use and security. Most building work carried out in England must comply with building regulations. The legal term building work generally includes constructing new buildings, extending buildings, altering buildings and changing what they are used for. It also covers installing a controlled service or fitting and includes renovation of a thermal element. The Building Act 1984 allows the government to publish approved documents. The approved documents contain statutory advice on how to meet the legal requirements of the building regulations in common building situations. Schedule 1 to the Building Regulations 2010 (as amended) sets out technical requirements that correspond to a letter. There is an approved document that provides guidance for each technical requirement. The technical requirement Part K to Schedule 1 of the Building Regulations (as amended) 2010 sets requirements for Protection from falling, collision and impact. Approved Document K provides guidance on how to meet the requirements of Part K for common building situations. Guidance or advice of best practice regarding the use of window restrictors to provide protection from falling is not given in the Approved Document K. Detachable window restrictors would not be suitable to provide adequate permanent protection from falling as there is always the potential that they could be left in an open position. Fixed window restrictors are often unsuitable as they may conflict with other requirements of building regulations such as provision for means of escape in the event of a fire, ventilation, and overheating mitigation strategies. In addition, window restrictors are often difficult to justify that, used in combination with the frame and glazing, can resist the horizontal force given in BS EN 1991-1-1. There is other publicly available guidance for implementation under Section 9 the Housing Act 2004 produced in relation to inspection of residential premises and assessing hazards. I advise that you speak to the Housing Standards team within Sheffield City Council who may be able to provide further advice as to how they would expect window restrictors to be used where hazards have been identified. I hope that this answers your question in the context of use of window restrictors to meet requirements of building regulations. It is SCC’s understanding that the windows installed, and the integral window restrictors, meet both building regulations and British standards and are therefore compliant with current guidance and regulation. However, the Council has instructed an independent Chartered Surveyor to undertake a review and prepare a report of the windows in high-rise Council blocks. The expert has been asked to comment on issues including: o Whether the current windows and restrictors are legally compliant. o The use of fixed restrictors and any impact the use of such restrictors would have on the compliance of the windows with Building Regulations or other relevant legislation. The chartered building surveyor who has been instructed has expertise in structural and defect diagnosis, and safety, health and environment issues. The Council has asked the expert to advise on risk assessing the windows and the factors to be considered. The Council intends to undertake a risk assessment of the windows following receipt of the expert’s report. It is anticipated that this report will be received by SCC, no later than the 14th June 2024. The findings of this report and any subsequent recommendations will be shared with the Council’s Housing and Repairs Improvement Board which is Chaired by the Executive Director of Neighbourhood Services. 2 More generally, I am concerned by Sheffield City Council’s in action in relation to the investigation and assessment of risk following cases of catastrophic injury and death within their social housing stock. I am concerned that a failure to properly investigate and risk assess any incident of this nature, together with the absence of any formal procedure or policy for this process, poses a risk of future death. There is no evidence before the inquest which alleviates my concern in this respect, in fact the inquest was told that the Head of Housing Investment and Maintenance for the council was not aware of the fatal incidents above until his attendance was required at this inquest. SCC acknowledge that following Saffra Winn’s death in June 2022 the process to ensure that there were no faults with the windows in the flat was insufficient and relied on documentary evidence from several sources to verify that each window operated as intended. However, following the death in December 2023, inspections of the flat windows took place as soon as possible by Housing staff to identify any issues. It was noted that in this case, again, all windows and restrictors operated as required with no issues reported. SCC has also instigated a new procedure and reporting framework which will log all reported fatalities and near misses from falls from high rise council accommodation and guidance outlining when a safety report is required on the functionality of the windows and restrictors. This guidance is currently going through the appropriate approvals process and will again be in place by 14th June 2024. Thankfully I can report that there have been no further fatalities from falling from tower blocks since the incident in December 2023. Also, this guidance will set out clear roles and responsibilities from the role of the Responsible Person, normally a Council Director, to who undertakes what function and when. It is also proposed that each fatality is reported to the Council’s Housing Policy Committee. SCC has also established a High-Rise Forum with window safety being an agenda item at its first meeting in June 2024. Officers will be sharing a Communications Plan which will look at providing routine information to all residents of high-rise buildings regarding window safety. SCC wrote to all residents in high-rise accommodation outlining window safety best practice. Also, guidance will be provided at the property sign up and we will also send out an annual communication to re-enforce window safety principles. Yours sincerely Head of Investment & Estates
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