Luke Brooks

Rt Hon Michael Gove MP 
Secretary of State for Levelling up, Housing & 
Communities 
Minister for Intergovernmental Relations 
2 Marsham Street 
London 
SW1P 4DF 

Joanne Kearsley 
Senior Coroner for the Coroner Area of Manchester North 
HM Coroner's Court Floors 
2 and 3 Newgate House 
Rochdale 
OL16 1AT 

Dear Joanne, 

3 October 2023 

RESPONSE TO PREVENT FUTURE DEATHS REPORT: INQUEST INTO THE DEATH OF LUKE 
MATTHEW BROOKS 

Thank you for your letter and investigative report (dated 17 August 2023) into the sad death of Luke 
Matthew Brooks, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners 
and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
In providing this response to the Report, we offer our sincere condolences to Mr Brooks’ family. 

On behalf of the Department for Levelling Up, Housing and Communities (“DLUHC”) I now want to 
outline our response to the Regulation 28 Report to Prevent Future Deaths concerning the death of 
Mr Brooks (“the Report”), which identified matters of concern and recommended that action be taken 
to prevent future deaths. 

The Report followed the investigation and the inquest into the death of Mr Brooks which commenced 
on 16 February 2023 and concluded on 10 August 2023. The conclusion of the inquest was that Mr 
Brooks died as a result of acute respiratory distress syndrome due to Aspergillus Pneumonia. Whilst 
the  inquest  considered  whether  the  Aspergillus  (fungi/mould)  was  linked  to  the  property,  the 
evidence  did  not  support  this.  The  source  of  the  Aspergillus  could  not  be  determined.  It  was, 
however, noted that Mr Brooks’ family had numerous concerns with the condition of the property 
over several years, which was cold and damp. 

The matters of concern identified in the Report are as follows: 

1.  There is no register of private landlords available in England. The court heard that this was out 
of step with other countries within the UK who had a national register. The lack of this meant that 
local authorities could be hampered in not knowing up-to-date address/contact details when they 
were made aware of concerns with a privately rented property. This is particularly important when 
the issue is one which is potentially life threatening, such as asbestos in a property, dangerous 
items such as inappropriate cord blinds in a property with children or excessive damp. 

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 2.  North West Ambulance Service (“NWAS”) had a local policy of advising people who described 
symptoms of chest pain (not immediate life threatening) to not attend A&E on their own. Whilst 
NWAS have now revised this policy to remove this, it is not known if this could be set out in the 
local policies of other ambulance services. 

This letter will respond to the first matter of concern. A separate response from the Department of 
Health and Social Care will respond to the second. 

First matter of concern: There is no register of private landlords available in England. 

We are taking action to address this. The Renters (Reform) Bill was introduced to parliament on 17 
May 2023 and includes provision for a new private rented sector database that will support the new 
Privately  Rented  Property  Portal  digital  service. Subject  to  parliamentary  approval,  all  private 
residential landlords (letting property in England via an assured tenancy under the Housing Act 1988 
or a regulated tenancy under the Rent Act 1977) will be legally required to register with the Property 
Portal, and to provide certain information relating to the properties they let. 

The service will help landlords understand their legal obligations and give tenants the information 
they need to make informed choices before entering into a tenancy agreement. 

The portal will also help landlords understand their legal responsibilities when letting property and 
provide  renters  with  a  new  information  source  to  see  relevant  information  about  a  landlord  and 
property. It  will  also  allow  local  housing  authorities  to  identify  poor  quality  and  non-compliant 
properties and who owns them, and take prompt action where appropriate. 

Other Government actions of relevance 

While you found that the condition of Mr Brooks’ property did not contribute to his death, I wanted 
to outline action that DLUHC is taking to tackle damp and mould and improve standards and property 
conditions in the private rented sector. 

This  September  I,  alongside  the  Secretary  of  State  for  Health  and  Social  Care,  published  our 
comprehensive guidance on understanding and addressing the health risks of damp and mould in 
the  home,  which  is  available  to  view  at:  https://www.gov.uk/government/publications/damp-and-
mould-understanding-and-addressing-the-health-risks-for-rented-housing-providers. 

This guidance was written in response to the tragic death of two-year-old Awaab Ishak in 2020, due 
to  mould  in  his  family  home.  It  provides  social  and  private  sector  landlords  with  a  thorough 
understanding of their legal responsibilities, and of the serious health risks that damp and mould 
pose. The guidance makes it clear that tenants should not be blamed for damp and mould. It is the 
responsibility  of  landlords  to  identify  and  address  the  underlying  cause  of  the  problem,  such  as 
structural issues or inadequate ventilation. 

In November 2022, I also wrote to Local Authority Chief Executives and council leaders setting out 
my expectation that they will take action to resolve poor housing conditions in their area and directing 
them  to  provide  information  on  current  housing  conditions  to  the  department.  A  summary  of 

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 responses  has  been  published  at:  https://www.gov.uk/government/publications/damp-and-mould-
in-the-private-rented-sector. 

My department will continue this work with Local Authorities, and I will be making £10m available to 
pilot measures to improve enforcement of damp and mould. This project is being run in conjunction 
with the Department of Health and Social Care, and the Department for Work and Pensions, and 
through it we hope to learn what approaches are most effective and the wider impacts of increased 
enforcement. 

I  am  committed  to  going  further  to  improve  property  standards  in  the  private  rented  sector  by 
introducing the Decent Homes Standard to the sector for the first time and intend to do so at the 
earliest available legislative opportunity. Work is currently underway to review the Decent Homes 
Standard to ensure it is up to date and fit for purpose. 

A core element of decency is assessed by the Housing Health and Safety Rating System (HHSRS), 
the tool used to assess hazards in rented homes. Following review of the HHSRS, our summary 
report on the outcomes and next steps is available to view at: 
https://www.gov.uk/government/publications/housing-health-and-safety-rating-system-hhsrs-
review-outcomes-and-next-steps. 

An updated HHSRS that is accessible to landlords and tenants and efficient for local councils to use 
forms a vital part of our reforms to both the social and private rented sectors. New regulations to 
bring the findings of the review into force will be introduced after the conclusion of our review of the 
Decent Homes Standard. 

The Government is committed to taking action to improve standards within the private rented sector. 
Thank you, once again, for providing your report. 

I am copying my response to the Secretary of State for Health and Social Care. 

Yours ever, 

RT HON MICHAEL GOVE MP 
Secretary of State for Levelling up, Housing and Communities 
Minister for Intergovernmental Relations 

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From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

17 May 2024 

HM Coroner Joanne Kearsley 
The Coroner’s Office, 
2nd and 3rd Floor, 
Newgate House, 
Newgate, Rochdale 
OL16 1AT 

Dear Ms Kearsley, 

Thank your letter of 17 August 2023  to the Secretary of State for Health and Social Care, 
Steve  Barclay,  about  the  death  of  Luke  Matthew  Brooks.  I  am  replying  as  Minister  with 
responsibility for urgent and emergency services. Please accept my sincere apologies for the 
delay in responding to this matter. I would like to assure you that the Department is mindful 
of the statutory responsibilities in relation to prevention of future deaths reports and we are 
prioritising responses as a matter of urgency. 

Firstly, I would like to say how saddened I was to read of the circumstances of  Mr Brooks’ 
death, and I offer my sincere condolences to his family. It is vital that we learn from incidents, 
where they are identified, to improve NHS care.  I am grateful to you for bringing these matters 
to my attention. 

The  report  raises  concerns  about  the  advice  North  West  Ambulance  Service  NHS  Trust 
(NWAS) gave to Mr Brooks which was to advise people who describe the symptoms of chest 
pain not to make their own way to A&E.  Your report raised a concern that although NWAS 
had revised this policy other ambulance services may have similar policies. 

In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS  England  (NHSE). 
NHSE has confirmed, after engaging with ambulance trusts in England, that no such blanket 
policies are in place. NHS111 calls are dealt with on a case–by-case basis. There may be 
instances where patients may be advised not to go to A&E on their own, including: 

•  Where patients with chest pain have no alternative but to drive themselves to A&E, 
then it may be recommended that patients wait for an ambulance in order to protect 
themselves and other road users; 

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 •  Where  an  ambulance  service  clinician  recommends  that  moving  a  patient  (e.g.  if 
extremely  unwell  or  at  risk  of  collapsing) may  do  more  harm  by  going  to  A&E  than 
waiting for the ambulance to arrive on scene. 

In addition, all patients calling 111 where it has been decided they need an ambulance, will 
be given interim advice which includes what to do should their condition worsen. 

Thank you for bringing these concerns to my attention. 

Yours, 

HELEN WHATELY 

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LADYBRIDGE HALL 
399 Chorley New Road 
Bolton 
BL1 5DD

nwas.nhs.uk 

Joanne Kearsley 
HM Senior Coroner 
Manchester North 

BY EMAIL ONLY 

21st September 2023 

Dear Ms Kearsley, 

Luke Brooks Inquest 

I  write  further  to  my  letter  of  9th  August  2023,  to  confirm  the  changes  that  have  now  been  made  with  

respect  to  procedure  and  policy  within  the  111  service  regarding  self-conveyance  to  hospital  and 

information passed to the Out of Hours provider in this case, which was Go To Doc. 

I will first address the former 111 policy relating to the exclusion of patients with chest pain from advice to 

make their own way to hospital. The revised policy now provides that all exclusions for self-conveyance, 

save for Category 1 incidents, will be removed, and patients will be asked if they can make their own way 

to hospital. These changes to the Standard Operating Procedure (SOP) were approved by the 111 SOP 

review group and then by the 111 Quality Business Group (QBG). 

The second point to address arose during the evidence of 

 when she agreed that Mr Brooks 

did not directly refuse an ambulance and only advised he was unable to make his own way to hospital. 

Your concern in this regard was fed back to the 111 service with the suggestion that advisors must be 

clear that a patient is refusing an ambulance disposition with this being confirmed directly with the patient, 

wherever possible. This guidance was also approved by the 111 SOP review group and then by the 111 

Quality Business Group (QBG).  

The  SOP,  reflecting  both  above  changes,  went  live  on  5th  September  2023  and  the  changes  were 
communicated to staff via the 111 SharePoint site (locally called OneSpace) in line with all SOP updates. 

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 Staff are provided with reading time across their duties to ensure that they are up to date on all changes 
within 111. 

I trust this update is sufficient, however should you require any further clarification or information, please 
do not hesitate to contact me. 

Yours sincerely, 

Solicitor 

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