Source · Prevention of Future Deaths

Brian Easey

Ref: 2020-0293 Date: 21 Dec 2020 Coroner: Bridget Dolan Area: West Sussex Responses identified: 2 / 2 View PDF

Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.

Date 21 Dec 2020
56-day deadline 5 Mar 2021 est.
Responses identified 2 of 2
Other related deaths

Coroner's concerns

AI summary
Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.
View full coroner's concerns
(1) In view of Mr Easey’s description of the dust present on the council records in both locations there appears to me a real risk that that these records were, and remain, contaminated with asbestos fibres; (2) Should there currently be asbestos fibres present on the records this presents a risk of asbestos exposure to all those whose come into contact with the records with an associated risk of developing fatal mesothelioma.

Responses

2 respondents
West Sussex County Council Local Authority / Fire Service
15 Feb 2021 PDF
Disputed

The council disputes that there is a risk of asbestos exposure, citing air monitoring and dust sample tests that did not identify the presence of asbestos in the storage rooms. (AI summary)

View full response
Dear Mrs Schofield

Our ref:

Re: Regulation 28 Report to Prevent Deaths Brian James Easey deceased

This letter is prepared by way of respnse to the Regulation 28 Report to Prevent Future Deaths prior to Inquest received under cover of your letter addressed to , Chief Executivce, such repsonse being required by the 15th February 2021.

This response is concerned only with the period of time in which Mr Easey was employed by West Sussex County Council within the Registration Service which we confirm from our own records was between the period 1st November 1984 and the 18th February 2006. For the period 1984 to 2000, Mr Easey’s place of employment was at Mill Road, Worthing where the records of births, deaths and marriages for the Worthing district were stored. In 2000, all records were moved to Centenary House in Worthing and at that time, Mr Easey’s employment was at Centenary House.

In 2010, the West Sussex Registration Service was unified and all records of births, deaths and marriages inluding those that had been moved from the Mill Road premises were moved from Centenary House to the County Records Office in Orchard Street, Chichetster.

Two concerns have been raised within the Regulation 28 Report. The first concern is that given the description of dust present on council records at Mill Road, Worthing, there appears to be a risk that such records were and remain Mrs Penelope Schofield Senior Coroner The Coroners Service County Record Office Orchard Street Chichester West Sussex PO19 1DD 12th February 2021

contaminated with asbestos fibres. To respond to this concern, arrangements were made for air monitoring for asbestos and dust sampling testing to be undertaken at the location that the records are currently held, that being the County Records Office. The testing was undertaken by Perry Analytical Limited – Analytical and Consultant Chemist. Copies of the reports prepared by Perry Analytical are enclosed.

The registers that are retained at County Records Office in Chichester, are stored in strong rooms 4 and 5. On the 22nd December 2020 air monitoring for asbestos tests were undertaken in strong rooms 4 and 5. Two samples for each room were taken and all samples tested identified an airborne concentration of asbestos of less than 0.01 fibres per millilitre. The report further comments that an airborne concentration of less than 0.01 fibres per millilitre is satisfactory, there only being a need to investigate further where there is a concentration of
0.01 fibres per millilitere or greater.

The samples of dust within strong rooms 4 and 5 were taken on the 31st December 2020 and analysed on the 4th January 2020. Eleven samples were taken in room 4 and four samples taken in room 5. The finding for each sample taken was that no asbestos was identified.

The second concern raised is that should there currently be asbestos fibres present on the records this presents a risk of asbestos exposure to all those who come in to contact with the records with an associated risk of developing fatal mesothelioma. Given that the findings of the air monitoring for asbestos in both strong rooms identified that the airborne concentration was satisfactory and secondly that the dust samples did not identify the presence of any asbestos, it is not appearnt that any one that comes in to conatct with the registers would have any exposure to asbestos.

It therefore follows that there is no requirement for the council to take any further action regarding either the location in which the registers are stored or the registers in question.

The council continue to do whatever it can to ensure the safety of its staff.

Shoud you require any clarification of the points made in this reposse, I would be grateful if you could please direct any points of clarification to the above address.
Lambeth Legal Services Local Authority / Fire Service
PDF
Disputed

Lambeth disputes Mr Easey's employment history description and states that reports confirmed no asbestos contamination of Registrar files. The Council will not take further action. (AI summary)

View full response
Dear Sir/Madam,

Re: Inquest into the death of Brian James Easey

1. Thank you for your letter of 8 February granting the Council’s request for an extension of time to reply to the Regulation 28 Report. We are now in a position to reply to that Report.

2. In summary, we can inform the Coroner that reports produced by Ayerst, an external asbestos specialist, following extensive inspections have confirmed that there is no contamination of the Council’s Registrar files that were once held at 340 Brixton Road (and at other offices used by the Council’s Registrar’s Office in the past). Further details are set out below. In view of these findings the Council does not intend to take any further action.

3. For present purposes the Council asks the Coroner to note that Mr Easey’s description of his employment history is disputed, some of the disputed matters are addressed below.

4. When the Record of Inquest (“ROI”) was issued on 5 January 2021 there was no evidence of asbestos contamination either at any of the Council’s premises or of any Council records. This differed from the situation at the Mill Road premises owned by West Sussex County Council where asbestos contamination was confirmed to exist in 1985 (see pages 32-34 of the bundle Your Ref:

Our Ref:

1 March 2021

previously provided to us by the Coroner’s office). In the circumstances, there was no basis for the ROI to refer to Lambeth Council at paragraph 3.

5. Given that the requisite evidence did not exist when the ROI was completed, and that the Council was not notified of the inquest or given an opportunity to participate or make any representations to it, and given the findings of the Ayerst reports, the Coroner is invited to amend (or revoke and re-issue) the ROI to remove any reference to asbestos exposure during Mr Easey’s employment with Lambeth Council. The Council asks for a response to this request within the next seven days.

6. The remaining paragraphs of this letter contain a more detailed response to the issues raised. Ownership of the properties in which the Registrar’s Office was situated
7. The Council has not owned 340 Brixton Road since at least 1982.

8. Land Registry records prior to 1982 are unavailable, however, the records show that 340 Brixton Road was owned by St Thomas’ Hospital Nominees from 1982 and that the property has been owned by Lexadon (Brixton Road) Limited since 11 February 2019, there were other owners in the intervening period.

9. The Council understands that extensive works were carried out to 340 Brixton Road (including to the basement where the strong room is said to have been situated) in or around 2011 when the building was converted into flats. There is limited information relating to inspections by the Council’s Building Control department which support this timeframe. There is no suggestion from the available records that any specialist works were required due to the presence of asbestos.

10. The Council sold 357-361 Brixton Road in 2004. The Land Registry records show that the property is currently owned by Lexadon Limited. Hambrook House was demolished in 2017. Mr Easey’s place of work
11. Mr Easey’s witness statement (§7) states that he was employed by the Council between 1965 to 1984. He states that he was employed as a Registrar and

later a Deputy Superintendent and that “for the duration of his employment” he was based at 340 Brixton Road (“340”).

12. It is accepted that Mr Easey was employed by the Council from 1 April 1965 until 31 October 1984 and that he worked for the Registrar’s office but it has not been possible to verify his job title/description.

13. Mr Easey cannot have been based at 340 for the whole period 1965 – 1984 because the building was not owned by the Council for the whole period. Further, the location of the Registrar’s Office moved before the building was sold. Fuller details on these matters are set out below. Location of Registrar’s Service and records
14. As advised in our letter of 8 February 2021, 340 Brixton Road was the main Registrar’s office but there were several satellite offices. For example, in 1967/68 it appears that Mr Easey was Registrar for the Lambeth North Sub- District and was based at 123 Kennington Road. Between 1971/72 and 1978/79 it appears 340 Brixton Road was used by the Registrar as a marriage office (only), births and deaths were registered at another building in Lambeth called Hambrook House and for at least some of those years Mr Easey appears to have been one of the Registrars of births and deaths (only). In 1979/80 the Registrar’s service moved to 357-363 Brixton Road which was used for births, deaths and marriages from this point until 2004 when it moved to Lambeth Town Hall. The Registrar’s Office remains at the Town Hall but some of the records have been relocated off-site.

15. The Registrar’s records date back to circa 1837 and there are approximately 8000 registers in total. The records for the period 1837 – circa 1960 and some records for subsequent years are kept in two secure air/temperature-controlled vaults at external sites in Essex (Rainham and Barking) managed by a company called Restore. The records held in Essex can be accessed by the Council’s employees on request. The remaining records up to the present day are kept in a secure vault at the Lambeth Town Hall. Accordingly, there are three locations at which records are currently stored.

16. The Council had commissioned detailed reports from external asbestos specialists in relation to the records held at each of these three locations, some of which will have been stored at 340 and/or 357-363 Brixton Road at some point in the past. The results of those tests are set out below under the heading “outcome of testing”. Outcome of testing by Ayerst
17. Ayerst has advised that because the building(s) in which Mr Easey worked are not available for inspection, the files that may have been kept in the buildings are the only remaining physical items that can be inspected in order to ascertain whether there is any future threat to life from anyone accessing the files in question. This accords with the observations made by the Coroner in her Regulation 28 Report as to the potential risk presented by asbestos dust present on records.

18. Out of an abundance of caution, the Council has commissioned detailed inspections by Ayerst of the files kept at each of the three sites. Ayerst advised that it would be reasonable to inspect a representative sample of the files (10%
- 800 files) to check for the presence of asbestos. The inspections included examining any packaging or storage receptacle the files came in. The outcome of these inspections which included both lab testing of debris found with the files and air sampling are as follows:

a. Files from Lambeth Town Hall, 1 Brixton Hill, Brixton, SW2 1RW were inspected on 1-2 February 2021: no asbestos detected
b. Files from Restore, 44 River Road, Barking, IG11 0DW were inspected during the week commencing 8 February 2021: no asbestos detected
c. Files from Restore, Unit 15 Easter Park, Ferry Lane, Rainham, RM13 9BP were inspected during the week commencing 8 February 2021 (the selected files were brought to the Barking Restore site for inspection): no asbestos detected
d. Air tests done at Lambeth Town Hall (on 11 January 2021) and both of the Restore sites (on 26 and 27 January 2021) raised no concerns of airborne asbestos fibres (airborne fibre concentration of less than 0.01 f/ml).
e. Air tests done daily during the above inspections raised no concerns of airborne asbestos fibres (airborne fibre concentration of less than 0.01 f/ml).

19. Copies of the reports are enclosed with this letter. We recommend the Coroner consider the document “Archive Records Investigation” first as this explains the nature or the extensive inspection conducted by Ayerst. There are four inspection reports in total as there were two specialists involved in the inspections of the Town Hall and Restore files and they prepared two reports each. There is a total of ten air test reports.

20. The Council is satisfied that its records are not contaminated with asbestos fibres and that there is no risk to those that come into contact with these files.

21. As previously advised, the Council has no records of any concerns of suspicions about asbestos contamination being raised by former or existing staff or anyone who may have handled the files from the Registrar’s Office. In the circumstances no further action is proposed.

22. We look forward to hearing from you in relation to the points raised at paragraph 5 of this letter within the next seven days.

Report sections

Investigation and inquest
On 16 December 2020 I commenced an investigation into the death of Brian James EASEY aged 79. The investigation has not yet concluded and the inquest has not been heard.
Circumstances of the death
Mr Easey was diagnosed with mesothelioma in September 2020. He provided a witness statement dated 21.10.20 setting out an account of his work exposure to asbestos as follows: In 1965 Mr Easey began working as a registrar for the London Borough of Lambeth and later became a deputy superintendent. He worked there for 19 years. Mr Easey believed that he was exposed to asbestos whilst working at 340 Brixton Road, on a daily basis he would frequently have to enter a fire-proof, strong-room repository room that is believed to have been clad with asbestos. The room was very dusty and the registers would be covered with layers of dust. He stated he often picked them up and used his arm to remove the dust or blew on it to disperse it. There was no ventilation was in the room. Mr Easey later started working for West Sussex County Council (WSCC) in 1984 as a superintendent registrar. For the first 16 years working for WSCC he was based at 15 Mill Road, Worthing. Mr Easey stated that he was exposed to asbestos in the fireproof repository, as the door contained asbestos and the walls were made from asbestos insulation boards. Mr Easey stated that he would enter the room frequently on a daily basis. Mr Easey would brush away the dust with his sleeve causing the dust to be released into the air around him. Mr Easey would often search for records and be leaning against the walls which would leave dust marks on his clothes. Mr Easey has stated that in around 2006 WSCC decided to relocate to Centenary House in Worthing and due to this Mr Easey spent a lot of time in the room moving records and preparing them for transportation. He described it as an extremely dusty process. He undertook this work alone and would be covered in dust by the end of his day. The records relocated to Centenary House were located in a larger modern strong room. In August 2020 Mr Easey began feeling breathless and as a result he was sent for a CT scan and tests. He was diagnosed with biphasic mesothelioma on 17 September 2020 and died from this condition on 13 December 2020.

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Report details

Reference
2020-0293
Date of report
21 December 2020
Coroner
Bridget Dolan
Coroner area
West Sussex

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Mar 2021 (estimated).

Sent to

Lambeth Borough Council
West Sussex County Council

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