Prevention of Future Deaths reports · 2024

William Erskine

Regulation 28 report to prevent future deaths, reference 2024-0204, written 17 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Apr 2024
Reference2024-0204
DeceasedWilliam Erskine
CoronerChris Morris
Coroner areaManchester South
CategoryAlcohol, drug and medication 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 

THIS REPORT IS BEING SENT TO:  Rt. Hon. Michael Gove MP, Secretary of State for Levelling Up, 
Housing and Communities 

CORONER 

I am Chris Morris, Area Coroner for Manchester South. 

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. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

INVESTIGATION and INQUEST 

On 13th September 2023, Alison Mutch OBE, Senior Coroner for Manchester South, opened an 
inquest into the death of William Erskine who died on 26th August 2023 on the Concourse of 
Stretford House, Chapel Lane, Stretford.  The investigation concluded with an inquest which I heard 
on 22nd March 2024. 

A post-mortem examination conducted by 
Office Register, concluded that Mr Erskine died as a consequence of multiple injuries. 

, Consultant Pathologist on the Home 

At the end of the inquest, I recorded a conclusion of Misadventure. 

CIRCUMSTANCES OF THE DEATH 

Mr Erskine died on 26th August 2023 on the concourse of Stretford House, Stretford, as a result of 
multiple injuries sustained when he fell or jumped from the open window of his 16th floor flat whilst 
his judgement was impaired through cocaine and alcohol use and following a recent violent 
altercation with his partner.  A police investigation has concluded there was no third party 
involvement in his death. 

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 will occur unless action is taken. In the circumstances it is my 
statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. – 

Mr Erskine was a resident of Stretford House, Chapel Lane, Stretford, M32 9AZ.  Stretford House is a 
23 floor residential block, comprising of 134 dwellings. The freehold owner of Stretford House is 
London and Quadrant Housing Trust, a Registered Provider of Social Housing. 

In the course of the evidence before the court, it was established that, whilst the windows in Mr 
Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can 
be released enabling the window to fully rotate within the frame (nominally to enable the resident 

 
 
 
 
 
 
   
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to clean the glass).  The degree to which the windows can be opened is therefore not restricted in 
the same way as if fixed window restrictors were fitted. 

1. 

It is a matter of concern that, aside from certain buildings designed for educational or 
healthcare use, or provided for vulnerable adults, current Building Regulations do not 
require fixed window restrictors to be fitted to opening windows in high-rise residential 
buildings; and 

2. 

In relation to windows of the type and design in use in Stretford House, there is no current 
requirement to retro-fit fixed window restrictors. 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action. 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 
12th June 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. 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner, Mr Erskine’s daughter and his partner, and to 
Devonshires Solicitors LLP on behalf of London and Quadrant Housing Trust. 

I have also sent a copy to Trafford Metropolitan Borough Council who may find it useful or of 
interest. 

I am also under a duty to send the Chief Coroner a copy of your response. 

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. 

Dated: 

17th April 2024 

Signature:  Chris Morris HM Area Coroner, Manchester South.

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 Ministry of Housing (PDF)
Rt Hon Angela Rayner MP 

Deputy Prime Minister and Secretary of State for 
Housing, Communities & Local Government 
2 Marsham Street  
London  
SW1P 4DF  

Your reference: 
Our reference: 

Christopher Morris 
HM Area Coroner 
Manchester South 
manchestersouthcoroners@stockport.gov.uk 

10 September 2024 

Dear Christopher, 

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS – INQUEST INTO 
THE DEATH OF MR WILLIAM ERSKINE 

Thank you for your letter and report dated 17 April regarding the tragic death of William Erskine. I 
would like to express my sincere condolences to Mr Erskine’s family and friends. 

Your letter and report were made in accordance with paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and Regulation 28 of the Coroners (Investigations) Regulations 2013.  You set out 
matters of concern and recommended that I, in my capacity as Secretary of State, and the Ministry 
of  Housing,  Communities  and  Local  Government  (MHCLG),  should  take  action.  Following  the 
General Election, a new Government has formed and I am grateful that you extended the period for 
my reply.   

You noted that: 

1.  aside  from  certain  buildings  designed  for  educational  or  healthcare  use,  or  provided  for 
vulnerable adults, current Building Regulations do not require fixed window restrictors to be 
fitted to opening windows in high-rise residential buildings; and 

2.  in relation to windows of the type and design in use in Stretford House, there is no current 

requirement to retro-fit fixed window restrictors. 

At  Mr  Erskine’s  Inquest,  you  established  that  falls  may  occur  when  somebody  is  in  a  confused 
mental state resulting from substance use or emotional distress. You found that when windows are 
fitted with locks and dual-position window restrictors, fittings can be released enabling the window 
to fully rotate within the frame for cleaning purposes; the extent to which windows can be opened is 
therefore not restricted in the same way as if fixed window restrictors were fitted. 

Consideration of the matters of concern 

I  have  set  out  below  how  Building  Regulations  apply  to  new  building  work.  People  who  design 
buildings and windows have to accommodate competing functional interests such as maintenance, 
providing an egress route in an emergency, ventilation, cooling or domestic hygiene. I consider that 
current legislative arrangements for new building work are both proportionate and appropriate. 

  
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 For tenants in existing buildings, risks of falls should be captured by existing housing standards, 
including the Housing Act 2004 and, for social housing tenants, the Decent Homes Standard, which 
I have described below. Changes introduced by the Social Housing (Regulation) Act 2023 (Awaab's 
Law) will also place a duty on social landlords to address hazards in homes in set timeframes; the 
Government is committed to bringing forward secondary legislation to bring Awaab’s Law into force 
in the social rented sector. The Renters’ Rights Bill will also apply both the Decent Homes Standard 
and Awaab’s Law to the private rented sector for the first time, which will mean that tenants in this 
type of accommodation will benefit from similar protection and redress.   

After careful consideration of both your matters of concern, I judge that no new regulatory action is 
necessary at this time, but the Government, of course, remains open to new evidence. I have set 
out the background behind my decision, below. 

Housing standards in the rented sectors 

There are standards in place that regulate the quality, decency and safety of rented housing. 

Under Part 1 of the Housing Act 2004 local housing authorities are required to keep the condition of 
housing in their area under review. Local housing authorities must take enforcement action if they 
think a ‘category 1’ hazard (as defined by the Housing Health and Safety Rating System) exists on 
housing  premises; this  includes hazards  relating  to  falls  between  levels.  It  should  be  noted  local 
housing authorities are unable to take enforcement action against themselves, where they are also 
the landlord. Under the Homes (Fit for Human Habitation) Act 2018, both private and social tenants 
are  also  able  to  take  their  own  action  through  the  courts  if  their  property  is  not  fit  for  human 
habitation. 

Social housing must also meet the Decent Homes Standard. This sets out that social homes must 
be free from dangerous category 1 hazards, free from disrepair, have modern facilities and provide 
a  reasonable  degree  of  thermal  comfort.  The  Regulator  of  Social  Housing  regulates  the  Decent 
Homes Standard in the social rented sector through its consumer standards, including the Safety 
and Quality Standard. This Government is committed to applying a Decent Homes Standard to the 
private  rented  sector  for  the  first  time  through  the  Renters’  Rights  Bill  and  we  are  reviewing  the 
Decent Homes Standard to make sure that it is fit for purpose in setting the minimum standards that 
all rented homes must meet. This will include consideration of whether specific measures on window 
restrictors should be included in the Decent Homes Standard.   

Social tenants can also contact the Housing Ombudsman if they are not happy that their landlord 
has  made  sure  their  home  is  of  a  decent  standard.  Private  rented  sector  tenants  can  escalate 
complaints about their letting or managing agents to one of two mandatory redress schemes. The 
Renters’ Rights Bill will also allow the Government to establish a new ombudsman service that will 
provide fair, impartial and binding resolution for tenants’ disputes with their landlord. 

Standards for New Building Work 

The Building Act 1984 is the most wide-reaching law controlling building in England. The Building 
Regulations 2010 (the Building Regulations) go into more detail about building work. Most building 
work  carried  out  in  England  must  comply  with  the  Building  Regulations.  The  legal  term  ‘building 
work’ is defined in the Building Regulations and generally includes new construction, extending and 
altering buildings and changing what they are used for; it also covers installing a controlled service 
or fitting.  The Building Regulations set standards which include accessibility, energy conservation 
and  security.  A  suite  of  statutory  guidance  (Approved  Documents)  is  published  alongside  the 
Building Regulations; the Approved Documents give guidance for many common building situations 
on how to meet the functional requirements of the Building Regulations. Powers in the Building Act 
and the Building Regulations are not retrospective however and cannot require an existing building 
to be modified or change its layout. 

 
 
 
 
 
 
 
 
 Approved Document K (‘Protection from falling, collision and impact’) provides detailed guidance on 
protection from falls.  Requirement K2, which has no limitations, requires provision to be made to 
prevent  people  from  falling  by  using  suitable  guarding  appropriate  for  the  circumstance.  
Requirement K5.3 provides that windows, skylights and ventilators which can be opened by people 
in  or  about  the  building  shall  be  constructed  or  equipped  that  they  may  be  opened,  closed  or 
adjusted safely; and Requirement K5.4 states that provision shall make windows safely accessible 
for cleaning but, as you are aware, these functional requirements have a limited application and do 
not apply to dwellings.  The guidance in Approved Document K notes that where a person may fall 
through a window above ground level, provision of suitable window limiters to restrain the window 
should be considered to prevent falls. The requirements which are applicable to dwellings are, as 
you  surmised,  in  place  to  minimise  risk  of  injury  to  the  householder  from  falling  in  their  living 
environment,  but  the  functional  requirements  set  out  in  Building  Regulations  are  minimum 
standards; there is nothing in Building Regulations or the limitations of application that would prevent 
a developer from going beyond those standards. 

Approved Document O (‘Overheating’) offers guidance on guarding. Where opening windows are 
included in a building’s design as part of a strategy to mitigate overheating, openings larger than 
100mm with a change in floor level between inside and outside of  more than 600mm must have 
guarding  up  to  1100mm.  This  can  be  provided  by  measures  that  include,  but  are  not  limited  to, 
shutters with a child-proof lock or fixed guarding that could also extend to unopenable part(s) of the 
window,  or  external  positioning  of  a  juliet  balcony.  Approved  Document  O  does  not  require  any 
restrictions on windows with a sill height of 1100mm or higher.   

Permanent window restrictors installed in dwellings to mitigate risk from falling from height could 
conflict  with  other  requirements  in  Building  Regulations,  which  may  include  providing  adequate 
ventilation, mitigating overheating, resistance to lateral forces and, in two storey buildings, means 
of escape in the event of a fire.  If mitigation of a risk from falling were reliant on guarding only, a 
permanent obstructing barrier such as a wall, suitably designed balustrade or glazing might be the 
most appropriate method of meeting Building Regulations.  

The Building Safety Regulator 

In 2022, a more stringent building safety regime was introduced overseen by the new Building Safety 
Regulator (BSR). The BSR has a statutory responsibility under the Building Safety Act 2022 to keep 
the safety of people in or about buildings, and the standard of buildings, under review and to make 
recommendations for improving standards to drive continuous improvement in the performance of 
all buildings to ensure the safety of occupants.  Notwithstanding the processes already in place that 
I have set out above, it would be appropriate for the BSR, as part of its continuous review work, to 
consider how Building Regulations and Approved Documents ensure protection from falling; and to 
look at coherence and the relationships between different elements of the Building Regulations and 
the extent of limits of application. I have therefore copied this letter to Philip White, the BSR Director 
of Building Safety and Chief Inspector of Buildings. 

Conclusion 

I have outlined above the Government’s plans to ensure that standards and legislation for rented 
homes provides a mechanism for tenants in rented accommodation to be assured that their homes 
meet appropriate standards of safety and, where they do not, redress should follow quickly.  

On Building Regulations, buildings and window designers always have to accommodate competing 
functional  interests.  Of  course,  the  Government  is  open  to  new  evidence  as  it  emerges,  but  I 
consider that current legislative arrangements are both proportionate and appropriate.  

 
 
 
 
 
 
 
 
 
 I fully recognise the seriousness of this incident but for the reasons set out above do not think that 
any additional measures need to be taken beyond the work already in train.  

Yours sincerely, 

RT HON ANGELA RAYNER MP 
Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government

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