Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0611, written 6 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2024 |
|---|---|
| Reference | 2024-0611 |
| Deceased | Sarah McGreevy |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| 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.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Operations Director, Tenancy and Homeowner Services, London Borough of Hackney 1 CORONER I am Sarah Bourke, HM Assistant Coroner, for the coroner area of Inner North London. 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 2 July 2024, HM Senior Coroner Mary Hassell commenced an investigation into the death of Sarah McGreevy aged 37 years. The investigation concluded at the end of the inquest on 6 November 2024. The conclusion of the inquest was that Ms McGreevy had died from injuries sustained when she fell from her balcony on 16 June 2024. I returned a conclusion of accident. The medical cause of Ms McGreevy’s death was: 1a multiple injuries, 1b trauma, 1c fall from height. 4 CIRCUMSTANCES OF THE DEATH Ms McGreevy was the assured shorthold tenant of . The property is a 2-bedroom flat on the 6th floor. The freeholder of the premises is London Borough of Hackney. Around 9.40 am on 16 June 2024, Ms McGreevy fell to the ground from her balcony and sustained fatal injuries. Police officers attended the scene and noted that there was a wooden box on the balcony and Ms McGreevy’s mobile phone was on a window ledge next to the balcony. The phone was close to a downwards drainpipe which came from the floor of the 7th floor balcony above Ms McGreevy’s flat before diverting down the exterior wall to the block. The pipe had previously been repaired using heavy duty tape. Residents made police officers aware of problems with the guttering and drainpipes in the block. Police were told of residents on the 5th and 6th floors climbing onto their balconies to manually unblock pipes, particularly following heavy rainfall. The Police investigation did not reveal any evidence to suggest that anyone else was involved in Ms McGreevy’s death or that she had any suicidal intent. Photographs taken of Ms McGreevy’s hands following her death show dirt around her fingernails consistent with undertaking a cleaning task. I found that it was more likely than not that Ms McGreevy had climbed onto the wooden box to clear the pipe and had accidentally fallen over the balcony. 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. – (1) Several residents reported a practice of climbing onto their balconies in order to clear blocked drainpipes. This practice carries a clear risk of falls. (2) The leaseholder of informed me that he was not aware of any work being undertaken to the guttering or drainpipes to the block following Ms McGreevy’s death. (3) In the absence of remedial works, the practice of residents unblocking pipes themselves is likely to continue. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1 January 2025. 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 Interested Persons: (1) (2) (parents of Sarah McGreevy) (leaseholder of ) 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. She 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 Sarah Bourke HM Assistant Coroner 6 November 2024
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.
Strategic Director Climate, Homes & Economy Hackney Service Centre 1 Hillman Street London, E8 1DY 19 December 2024 Dear HM Senior Coroner, Sarah Margaret Mary McGreevy (died 16.06.24) Thank you for your Regulation 28 Report to Prevent Future Deaths following the Inquest into the sad death of Sarah McGreevy. The role of the London Borough of Hackney The role of the London Borough of Hackney as a London Borough has The Borough is responsibilities, amongst other responsible for a variety of dwellings including tower blocks. The Borough is the freeholder of Macbeth House which is an eight storey concrete framed residential block of flats with a communal walk way balcony to the front and private balconies to each dwelling to the rear. for social housing. things, Prevent of Further Deaths Report In the Regulation 28 Report you asked the Borough to consider the following concern: 1 2 3 Several residents reported a practice of climbing onto their balconies in order to clear blocked drainpipes. This practice carries a clear risk of falls. The Leaseholder of Flat informed me that he was not aware of any work being undertaken to the guttering or drainpipes to the block following Ms McGreevy’s death. In the absence of unblocking pipes themselves is likely to continue. remedial works the practice of the residents Response The Borough had no knowledge of the inquest hearing, was not requested to provide any evidence to support the inquest nor were we invited to attend and give evidence, the first notification was the Prevention of Future Deaths report from HM Coroner. The Borough is the freeholder of Macbeth House and is responsible for the structure. N & S Arden are the Tenant’s Management Organisation (TMO) and they are responsible for the maintenance and cleaning of the common areas and grounds of the Estate. Each flat has a private cantilever concrete balcony to the rear which is accessed via a separate UPVC glazed door from the living room and are finished with asphalt with a kerbed sole gutter to the outer edge of the balcony floor which is laid to falls and discharges into a gully outlet through the balcony into a UPVC 75mm surface water drainage stack. At the base where the gully passes through the slab a branch is installed directing the drainage to the vertical 75mm stack. This accommodates a screw on end rodding eye access cap. The balconies are framed balustrading consisting of the frame, replacement provided with metal sheet infill panels to the front and original Georgian wire glass to the sides. A replacement handrail is fixed above the panels at a height of 1165mm above the finished floor level. A number of balconies have been provided with pigeon netting. Following receipt of the Prevention of Future Deaths Report a search was conducted on the housing repairs system to identify any reports of blockages or defects in relation to the balcony surface water drainage stack. A search was conducted in respect of the block as a whole and individual flats. No reports had been received for any Works Orders. Enquiries were further undertaken with the TMO and they have confirmed no reports of any defects or request for repairs were made. At no point are tenants / leaseholders expected to undertake repairs to, or unblocking of gutters / fall pipes. A report for repairs can be made directly to the Borough online for non-emergency repairs or via the repairs telephone number 0208 356 3691. Non-emergency repairs are answered during office hours 9am to 5pm Monday, Tuesday, Thursday and Friday and 9am to 4pm Wednesday. Alternatively, non-emergency repairs can be raised via the TMO as Leasehold tenants may not be aware of the reporting procedure. The tenant’s management organisation operates Monday to Friday, 8am to 4pm, from an office in the Arden Estate immediately adjacent to Macbeth House. The repair timescales for a normal repair, namely non-urgent, would be within 21 working days. Surface water drainage systems are not subject to periodic inspection and are reactive in nature. Action taken A condition survey was undertaken from ground level on Monday, 25 November 2024 by the Borough’s Area Surveying Manager, and the TMO Manager. The survey was to examine the external elements and elevations with particular attention being given to the condition of surface water drainage serving the balconies to the rear of the block. ), nor of the exposed concrete surfaces of any other balconies. No defects were noted to the surfaces or elements of the balcony inspected (Flat In respect of ) surface water drainage serving all balconies, except for Flat adhesive tape had been applied to the sofit of no defects were noted. At Flat Flat which is likely to have been placed as a temporary repair to hold the horizontal section in place. To clarify such temporary repair was not undertaken by the Borough nor the TMO. ’s balcony from Flat (the sofit of Flat A works order had been raised following the tragic incident, but access could not be gained to the flat. Plumbers attended following the survey on 27 November 2024 and noted the pipework was secure, free flowing and no repairs were required. It is not clear as to why tape had been applied to the same. The Borough produces a publication called ‘Love Hackney’ which is printed 10 times a year and 120,000 copies delivered to homes and businesses in each publication cycle. The magazines are also available at pick up service points across the Borough and is available on the Borough’s website. The publication provides information including articles under the title ‘Housing Info’ which is for tenants and leaseholders. The January edition will provide a general council message regarding keeping residents, families and neighbours safe in their homes and to remind occupiers that if you have a balcony not to use steps, stools or ladders on the balcony and if any repairs need to be carried out, including issues with guttering or pipe works to contact the repairs contact centre. We hope that this response addresses your concerns. Should you require any further information please do not hesitate to get in touch. Yours sincerely Strategic Director Housing
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