Source · Prevention of Future Deaths

Matthew Willoughby

Ref: 2020-0016 Date: 19 Jan 2020 Coroner: Alan Wilson Area: Blackpool & Fylde Responses identified: 1 / 1 View PDF

A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.

Date 19 Jan 2020
56-day deadline 4 Apr 2020 est.
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.
View full 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.  You have a number of tenants.    I was not reassured that the adaptions removed from the window in the flat from which  Matthew fell have since been replaced.   Acknowledging that Matthew removed the adaptions himself, and that his reason for so doing  was because he preferred to be able to open the window fully, as you advised in court an  Inspector had advised that they be put in place and on grounds of safety.    Regardless of whether you and / or your Husband advised Matthew that the adaptions were  necessary, Matthew went on to reside in one of your flats for many months during which the  window was able to open to the extent it could before the adaptions were added.   There is a concern that if a Tenant of yours is intent on residing in conditions which are at odds  with advice you have been given on grounds of the safety of your tenants and no action is taken  by you as a Landlord beyond occasionally raising it with the Tenant, then this poses a risk to  your current and future tenants.

Responses

1 respondent
Landlord Other
25 Feb 2020 PDF
Action Taken

The landlord confirms the adaptations to the windows in flat 10 have been replaced and all top floor flats windows have been checked for safety. (AI summary)

View full response
Dear Sir Further to your letter in response to the above 's recent demise in which you state we had a duty to notify you of when we replaced the adaptation to flat 10 window: am informing you that we have replaced the stated adaptations to the windows in flat 10 .and checked all the top floor flats windows were safe too. We have enclosed photographic evidence of the same for your perusal:

Report sections

Investigation and inquest
On 15/01/2020 I concluded an inquest into the death of Matthew WILLOUGHBY.  

I determined that the medical cause of death was: 

1a Multiple Injuries b Fall from high altitude

In the Record of Inquest I recorded that: 

Matthew Willoughby was observed to lean out of a fourth floor window at the flat where he resided and shout to a passer – by on the afternoon of 9th August 2019 at approximately 15:30hours but inadvertently fell from the window to the ground below where he was found by members of the public in the back yard of the property. An ambulance was contacted and he was transferred to hospital in Preston where it was confirmed that he had suffered significant brain and internal injuries. Despite life-saving efforts his injuries were found to be incompatible with life and he was pronounced deceased at approximately 23.35 hours that evening in the presence of his family.

The conclusion of the Coroner was that Matthew had died due to: 

Accidental death.
Circumstances of the death
In addition to the information set out above in part 3, the following is relevant: 

Matthew was 27 years of age at the time of his death. For approximately 4 years he had resided at  in Blackpool. The property is a four story building comprising of a number of flats rented  out to tenants by the owners of the property namely  and her Husband. For  approximately 2 years prior to his death on 9th August 2019 Matthew had resided in a flat on the top  floor.  The evidence heard at the inquest illustrated that at the time of his death Matthew had fallen from his  one external window which overlooks the rear of the property and that the window was capable of being  opened sufficiently for a person to climb out of the window should they choose to. The evidence was  also clear in that immediately before he fell to his death Matthew had been seen leaning out of his  window to what was described by one witness to be a dangerous manner.  He was known to be a regular cannabis user but there was insufficient evidence to be able to conclude  that he was under the influence of cannabis at the time of the incident to the extent this made a material  contribution to the death.  

attended the inquest and gave evidence. During her evidence she brought to the attention  of the court some information not previously mentioned in the witness statement she had provided  shortly after this reported death. 

That information included the following: 

 Matthew as someone who preferred a fresh environment in his flat and was therefore known to  keep his flat window open at all times [his Parents who were in attendance at the inquest were  in agreement with this.]   Approximately 14 months before his death a Blackpool Council Inspector visited and advised  that on grounds of safety the window in Matthew’s flat ought to be adapted on the basis that  adaptions be added to the window which would effectively restrict how far the window could be  opened and that these restrictions would effectively restrict the extent to which the window  could open so that it would no longer be possible for a person to climb out of that window.    These adaptions had been added. However in due course Matthew had removed them. He was  unhappy that they prevented him from fully opening the window. He Parents agreed that this  was something that he would have preferred to do.   informed the court that her Husband had spoken to Matthew at least four times  since their removal and advised against the removal but by the time of death the adaptions had  not been re‐placed.    In the opinion of  neither she nor her Husband had notified the Council about the  adaptions being removed.    At the conclusion of the inquest I informed  that I planned to write to her because  I had a concern about the risk of future deaths.
Copies sent to
I have also sent a copy to the Chief Executive of Blackpool Council in the event he should find it useful orof interestI am also under a duty to send the Chief Coroner a copy of your responseSignature

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Report details

Reference
2020-0016
Date of report
19 January 2020
Coroner
Alan Wilson
Coroner area
Blackpool & Fylde

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: 4 Apr 2020 (estimated).

Sent to

Landlord

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