Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 25 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Aug 2018 |
|---|---|
| Deceased | Kenneth Brincombe |
| Coroner | Caroline Saunders |
| Coroner area | Plymouth Torbay and South Devon |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Caroline SAUNDERS Assistant Coroner for Plymouth Torbay and South Devon bf REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Guinness Care and Support Director of Adult Care Devon County Council CORONER | am Caroline SAUNDERS, Assistant Coroner for Plymouth Torbay and South Devon CORONER’S LEGAL POWERS | 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 15 November 2016 an investigation was commenced into the death of Kenneth Arthur Brinicombe, 81. The investigation concluded at the end of the inquest on 25 August 2017. The conclusion of the inquest was ACCIDENT. CIRCUMSTANCES OF THE DEATH Mr Brinicombe was an 81 year o!d gentleman who suffered from various health problems which rendered him immobile and significantly visually impaired. His one pleasure was smoking, however in light of his mobility and sight problems and his lack of manual dexterity he was at high risk of accidentally starting a fire. On 31 October 2016 those fears were realised. Mr Brinicombe accidentally set fire to himself when smoking and died as a result of the burns he sustained. 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 Brinicombe was aware that his smoking put him at a high risk of starting a fire. He wanted to continue smoking and had capacity to make this decision. However this could only be achieved if carers provided him with cigarettes and matches. They could not supervise him smoking. | am concerned that: (1) There was an assumption that because Mr Brinicombe wanted to smoke that the carers had no choice but to facilitate this despite putting Mr Brinicombe and his neighbours at risk of death by fire. (2) In evidence the carer confirmed that the carers were responsible for maintaining a safe environment, but had no training in how to assess whether the house and the appliances were safe or whether they posed a fire hazard. (3) Mr Brinicombe had received advice and had three smoke detectors fitted, however these would only alert Mr Brinicombe to the fire. The smoke detectors would not alert a fire station, and in Mr Brinicombe’s level of disability he would be unable to take evasive action. 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. (1) Confirm the process of undertaking risk assessments in the home of a vulnerable adult, who cannot ensure the safety of his/her environment, and confirm the training the staff have to identify fire hazards. Describe what measures should be taken when carers are being asked to facilitate an activity which will endanger the lives of the individual concerned and others. Confirm whether in the future, where a vulnerable adult is at high risk of accidentally starting a fire, putting himself and others lives in danger, and being unable to take any action if this occurs, that smoke detectors would be fitted that have a direct link to a fire station. (2 as (3 = YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 October 2017. |, 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 | have sent a copy of my report to the Chief Coroner and to the Devon and Somerset Fire and Rescue Service who may find it useful or of interest. lam 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 25 August 2017 Signature Cha Is Assistant Coroner for Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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