Source · Prevention of Future Deaths

Jaden Francois-Espirit

Ref: 2021-0048 Date: 22 Feb 2021 Coroner: Mary Hassell Area: Inner North London Responses identified: 1 / 1 View PDF

The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.

Date 22 Feb 2021
56-day deadline 19 Apr 2021 est.
Responses identified 1 of 1
Emergency services related deaths (2019 onwards) Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.
View full coroner's concerns
Unbeknown to those with whom he worked at Wembley Fire Station, Jaden’s mental well being was deteriorating significantly in the last weeks of his life, and it deteriorated to the point where he killed himself.

I heard at inquest that the London Fire Brigade has quite sophisticated systems in place to support firefighters suffering mental ill health. However, Jaden was not offered the support of, for example, psychological counselling, because it was not appreciated that he was so very low.

Obviously if firefighters are to be given the best chance of recovering from mental ill health, their difficulties first need to be recognised.

I appreciate that it can be difficult to detect that a person may be depressed or exceptionally unhappy. Signs may be subtle and require a nuanced approach.

 Jaden often complained that he was bored because Wembley Green Watch had not been called to many incidents. I heard evidence that boredom in a new firefighter can be quite common. However, I also heard that a complaint of boredom can be a sign of a person with dyslexia avoiding an unpalatable or daunting task.

 Jaden had dyslexia and was worried that he would not be able to complete his written work in order to become a fully qualified firefighter, yet the reality was that his station officer was fully aware of his difficulties and had tried to reassure Jaden that he was certainly capable of achieving his goal.

 He did need extra time, the space to make mistakes and a degree of sensitivity that was not always afforded him. On the other hand, he asked for help and was given a mentor, but did not make use of him and so eventually the mentorship ceased. That request for help followed by a refusal of help was not explored. Such an exploration might have led to a greater understanding of how Jaden could be helped.

 Jaden felt he was being treated unfairly at work and his family have formed the view that there was an element of racism there, driven in part by their belief that Jaden was the only non white person on Wembley Green Watch. Yet the reality was that he joined a watch where a quarter of the firefighters were people of colour.  He described being teased about bringing chicken, rice and peas to work to eat, thinking that this teasing was because the food was Caribbean. Looking at this from the outside, chicken, rice and peas seems a dish without obvious world origin. Moreover, I heard about a huge variety of food being brought to work by firefighters, with some even weighing their food before eating. None of this sits easily with a dish of chicken, rice and peas resulting in a racist comment.

Jaden’s interior life did not always accord with what was going on around him. Most of all he felt isolated, and yet it was clear to me that he there was a lot of affection for him at the fire station. He did not always feel comfortable there. It is not necessarily an easy task to unearth such feelings in a colleague but, if it results in such a tragedy as this being avoided, it is a worthwhile one.

I should be grateful if you, or whoever you delegate to investigate this matter, would listen to the entirety of the recording of this inquest. The London Fire Brigade investigation report already produced, talks in some detail about the station culture. There were so many different aspects to the evidence that, without listening to the whole inquest, I am afraid that any understanding will not be as meaningful as it could be.

Responses

1 respondent
London Fire Brigade Local Authority / Fire Service
10 Jun 2021 PDF
Action Taken

LFB accepted all 24 recommendations in the investigation report following the death of Jaden Francois-Esprit, and created an action plan, extended to include the coroner's concerns, with a total of 32 actions. As of June 10 2021, nine of these actions have been completed across 11 broad areas including recruitment, training, support and culture. (AI summary)

View full response
Dear Coroner Response to Regulation 28: Prevention of Future Deaths Report I write in response to the prevention of future deaths report ['PFD report') you issued following the inquest touching the death of Jaden Francois-Esprit. I am grateful that you have noted the contents of the London Fire Brigade ['LFB'J investigation report, which was produced in response to Jaden's death. As you know that report identified a number of areas in which the Brigade could better serve its employees, particularly in the initial stages of their employment. LFB action plan following Jaden's death ln advance of the inquest all 24 recommendations in the investigation report were accepted by LFB's senior leadership team. These were turned into an action plan for change across the organisation. On receipt of your PFD report the action plan was extended to include the matters of concern raised therein. so far as they were not already identified by the LFB. A copy of the plan, with the status of actions as at 10 June 2021, is annexed to this letter. There are a total of 32 actions which LFB must complete to address the concerns you have raised in the PFD report and to fulfil the recommendations of its internal report. These have been grouped into the following 11 broad areas: (1) Recruitment. Training and Learning Support; (2) Trans fer System: (3) Support to FF(D)s whilst at Station; (4) Finance (5) Allocation (6) Other (7) Support for Death in Service (8) Culture (9) Sharing the findings

(10)Proactively Identifying Mental lii-Health (11 )Further investigation Responsibility for each action has been assigned to a senior leader in the Brigade (i.e. Commissioner, Assistant Commissioner or Assistant Director) with a named senior officer tasked to complete the required work. Completion dates have been set for each action. Of the 32 items listed on the plan nine have been completed. The remaining 23 are expected to be concluded in line with either the target date set or a revised date. which will be monitored by the People Board. The action plan is a standing item at the monthly People Services Board. led by the Director of People and attended by all Directors of LFB. This provides the scrutiny required to ensure completion of all agreed actions. Accordingly, all outstanding items will continue to be closely monitored. I hope this response provides you with the necessary assurance of the LFB's commitment to further improving the mental health of all its staff. London Fire Commissioner

Report sections

Investigation and inquest
On 3 September 2020, I commenced an investigation into the death of Jaden Francois-Esprit, aged 21 years. The investigation concluded at the end of the inquest on 15 February 2021. I made a determination of suicide.
Circumstances of the death
Jaden hanged himself at home on the 25th or 26th of August 2020. In the last few weeks of his life he became more withdrawn, including at his place of work as a firefighter. He felt isolated, though in reality he had friends there and was well liked, as well as being loved by his family.
Copies sent to
, Jaden’s mum

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Report details

Reference
2021-0048
Date of report
22 February 2021
Coroner
Mary Hassell
Coroner area
Inner North London

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Apr 2021 (estimated).

Sent to

London Fire Brigade

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