Kane Davidson

Coroner's concerns

AI summary

The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and tenant certificates are misleading.

View full coroner's concerns

In the conduct of this Inquest, the Court received evidence which pointed to a serious matter of concern. In such circumstances, it is my statutory duty to report those concerns to you.

1. The council has resolved to establish and implement a regime of landlord license registration pursuant to, inter alia, section 88 of the Housing Act 2004.

2. The resultant application process culminates in the grant of a license without any prior audit of the landlord's premises.

3. Where an audit of residential property is undertaken, there is no express obligation upon the person conducting the audit or assessment to refer to other risks to which children might be exposed, including, those posed by internal blinds.

4. This remains the position notwithstanding the fact that the council was on notice of such risk and indeed had issued guidance to those undertaking inspections. The nature and character of the risk posed by such equipment was not accommodated within any documentation to which the Court has been given access.

5. There is an absence of clarity as to the enforcement action, if any, to be taken by the Council in the event of a licence holder failing to comply with the conditions of the licence.

6. The form of certificate issued to Landlords does not make sufficiently clear to actual or prospective tenants:

(1) that the issue of the certificate cannot and should not be taken as an endorsement of the premises to which the certificate relates; (2) that the premises to which the certificate relates and/or in respect of which the landlord is licensed should not be assumed to be compliant with the relevant safety standards.

7. The conditions of licence are insufficiently clear in communicating the obligations upon the licence landlord and/or that the landlord remains personally liable for compliance with the licence conditions notwithstanding the use of any intermediary letting agency.

Responses

2 respondents

Oldham Council Local Authority / Fire Service

26 Jul 2022 PDF

Action Taken

Oldham Council has amended the wording on licenses, added blind cord safety as a license condition (checked at every property visit), briefed enforcement officers on blind cord safety, and added related information to the Council's website. A new selective licensing scheme was also reintroduced in July 2022. (AI summary)

View full response

Dear Dr Edward Morgan QC, I would like to take this opportunity to formally respond to your Regulation 28 report dated to prevent future deaths dated 26th July 2022, relating to the tragic circumstances surrounding the death of Kane Thomas Harley Davidson. As background, I can confirm that the Council implemented a Selective Licensing Scheme for privately rented properties in 2015 and that lasted for 5 years. This scheme only applied to certain selected areas of the Borough and required landlords with rental properties to apply for a licence. The Council has recently reintroduced a new scheme in July 2022, that again covers certain areas of the Borough and requires all landlords in these areas to apply and pay for a licence. All the procedures implemented as part of these schemes, including the granting of a licence without any prior audit of the landlord's premises were carried out in accordance with the Housing Act 2004 provisions. The selective licensing scheme doesn't require the Council to carry out an audit of every property that is licensed and the scheme only covers a percentage of privately rented properties in Oldham, therefore there will be many more privately rented properties that the Council is unaware of and therefore won't be able to give advice on blind cord safety or check that they comply. There are also a large number of Local Authorities that do not have a licensing scheme in their location making tackling this issue potentially national issue in the privately rented sector. Can I suggest that as part of your considerations it should be highlighted to the Government's Department of Levelling Up, Housing and Communities (DLUCH) the dangers and inconsistency across the Country without national legislative intervention. I can confirm that here in Oldham the Council has already made the following improvements in response to your notification and as part of the paperwork issued as part of the Licensing scheme :
• The wording on the licence has been amended to make it clear that the licence holder is responsible for adhering to the licence conditions as well as ensuring the property meets the standards of the Housing Act. The licence is issued to the most appropriate person and in some cases this maybe the letting agents or another person who has significant control of the property. It is also made clearer in the documentation that the licence does not indicate that the property has been assessed against any standards and that it is up to the licence holder to carry out regular checks to make sure the property meets legal requirements.
• As the Council has discretion regarding the licence conditions that form the basis of the selective licensing scheme, these have been amended to include blind cord safety as a licence condition and this will be checked at every property visited by the Council's Environmental Health team both as part of any audit of a property and also as part of an inspection in response to any other reported issue.
• It is now made clearer on the licence that any breaches of the licence conditions will result in legal action.
• It is also explained on the documentation that the award of the licence is not an endorsement of the property
• Information and a link to the appropriate government website is now on the Council's website. Please see the link for your information - Selective Licensing of private landlords | Selective Licensing of private landlords | Oldham Council

• All Enforcement officers within the team who inspect residential properties have been briefed as to the importance of blind cord safety and instructed to check any issues with blind cords at all properties that they visit. Many thanks

, Chief Executive Oldham Council For Satnav purposes please use OL1 1NL Visiting the Civic Centre by Metrolink? The nearest stop is Oldham King Street (2 - 3 mins' walk)

Department for Levelling up Housing Communities Central Government

30 Sep 2022 PDF

Noted

The Department acknowledges the coroner's concerns but believes awareness campaigns are key. They support RoSPA's 'Make It Safe' campaign and will consider how to strengthen its reach. (AI summary)

View full response

The Rt Hon Simon Clarke MP Secretary of State for Levelling up Housing & Communities

Department for Levelling Up, Housing and Communities 4th Floor, Fry Building 2 Marsham Street London SW1P 4DF

Dr Edward Morgan HM Coroner - Manchester North HM Coroner's Court Floors 2 & 3 Newgate Rochdale Lancashire OL16 1AT

30 September 2022

Thank you for your Regulation 28 Report of 27 July 2022. I’m deeply sorry to hear of Kane Davidson’s death and my sympathies are with his family. I am of course reminded of two similar tragic incidents that occurred in the last few years. I take the health and safety of all people, and children in particular, very seriously and therefore thank you for raising this important matter with me.

Having considered this issue extremely carefully, however, I am not of the view that new legal requirements on the private rented sector will achieve the outcomes we desire – namely the removal of dangerous looped blind cords from all residential accommodation as soon as possible. This is an issue that affects people in homes of all tenures, not just private renters.

Instead, I believe that campaigns to raise awareness of this issue are the key. This is why my department has supported the work done by the Office for Product Safety and Standards (OPSS), at the Department of Business, Energy and Industrial Strategy (BEIS), who have responsibility for regulation of the safety of consumer products like window blinds. The Government, through OPSS, continue to fund the Royal Society for the Prevention of Accidents (RoSPA) to raise awareness of safety risks, including the importance of noting warnings and following safety instructions where they are included.

RoSPA are leading a campaign, supported by the Government, to highlight the potential dangers of looped blind cords, particularly among families with small children. Their ‘Make It Safe’ campaign along with safety information is available at https://www.rospa.com/campaigns-fundraising/current/blind-cord. My officials have worked with their colleagues at OPSS to further publicise this campaign, through our newsletters to landlords and local authorities and our suite of guides for private rented sector landlords and tenants (https://www.gov.uk/government/collections/housing-how-to-guides) that cover safety in rented properties.

I will provide my full support to reviewing these campaigns and have asked my officials to consider how to strengthen their reach so that this message is seen and understood by everyone, including tenants, landlords and their agents. I hope that this letter assures you that the government takes this matter very seriously.

RT HON SIMON CLARKE MP Secretary of State for Department for Levelling up, Housing and Communities

Report sections

Investigation and inquest

On 9 February 2022, Mr Matthew Cox, Assistant Coroner commenced an investigation into the death of Kane Thomas Harley Davidson.

Circumstances of the death

On 28 January 2022, Kane Thomas Harley Davidson (Kane) was found unresponsive in the bedroom of his family home address

Following attendance of the emergency services, he was transported to Royal Oldham Hospital. Clinical assessment rendered it necessary that Kane was transferred for specialist care at Royal Manchester Children's Hospital. Despite the sustained efforts of specialist clinicians, it was apparent that Kane had suffered extensive "widespread diffuse hypoxia pattern of ischaemic brain injury". Kane's physical condition declined and he sadly died on 1 February 2022. There is no evidence of suspicious circumstances or third party involvement in his death. At the material time, the family lived in a privately rented property. The letting was managed on behalf of the landlord by professional letting agents. Prior to entering into that letting arrangement, the landlord had applied for and obtained a private licence from the Local Authority pursuant to section 88 of the Housing Act 2004. The licence was issued without prior inspection or audit of the proposed rental property. The issue of such a licence is predicated upon the basis that the landlord or appropriate licensed individual would continue to maintain the premises in a condition of safety from material hazards. The window blinds at the property had-according to the landlord-been in situ for many years and before the date that Kane and his family moved into the property. They were not the subject of assessment for risk or review in advance of the residential letting arrangement to which Kane's parents were parties. The window blinds were not compliant with the British Standard EN13120 in that they did not incorporate the necessary safety features as required by those standards. Those standards are applicable, inter alia, to those homes where children under the age of 42 months are likely to be present.

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2. The Child Accident Prevention Trust

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