Source · Prevention of Future Deaths

Simon Barber

Ref: 2019-0036 Date: 28 Jan 2019 Coroner: Tanyka Rawden Area: Nottinghamshire Responses identified: 1 / 1 View PDF

Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.

Date 28 Jan 2019

56-day deadline 21 Jul 2019 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.

View full coroner's concerns

The MATTER OF CONCERN is as follows. – Evidence was given before the Court that the risk assessment carried out First Class Care was inadequate.

In my opinion there is a risk that future deaths may occur unless adequate risk assessments are carried out by First Class Care and staff are made aware of the importance of reporting all incidents that endanger the safety of service users

Responses

1 respondent

Nottingham City Council Local Authority / Fire Service

28 Jan 2019 PDF

Action Taken

Nottingham City Council has reviewed its Ramping policy to explicitly consider two ramped points of access where there are significant risks or increased fire risk. A commitment has been made to completing risk assessments for all citizens moving into suitable accommodation. (AI summary)

View full response

Report in response to the Regulation 28 notice received by Nottingham City Council following the inquest held into the death of Simon Paul Barber.

This report is in response to the regulation 28 notice dated the 28th January 2019 which was sent to , Director for Adult Social Services, Nottingham City Council following the inquest held on the 17th January 2019 into the death of Simon Paul Barber.

The matter highlighted in the regulation 28 as giving rise to concern was “a risk that future deaths may occur unless risk assessments are carried out in a timely fashion and sufficient exits are made available to service users in the event of an emergency”.

Action already completed

In order to address this concern, Nottingham City Council’s Occupational Therapy Service’s Ramping policy has already been reviewed in order to reflect explicitly that, if there are significant risks to the resident associated with just one ramped access, that this would necessarily require consideration of two ramped points of access as would any indication of an increased fire risk which has not been mitigated sufficiently with the implementation of the recommendations of Nottinghamshire Fire and Rescue Service. It is important to highlight that it is not always possible to make adaptations to certain properties due to the building layout, and in these circumstances it would usually be recommended that alternative properties would be more suitable for that specific citizen.

Planned Action

A commitment has already been made by Nottingham City Homes and Nottingham City Council’s Occupational Therapy and Adaptations services to the completion of risk assessments for all citizens moving into suitable accommodation via the Disabled Housing Advisor service. It has been agreed that the Disabled Housing Advisors would be best placed to co-ordinate the completion of these risk assessments, since they are familiar with the layout of properties and are in receipt of pertinent information relating to each citizen.

Currently, there are two Advisors to deliver the service to all the citizens who may need this each year and, therefore, an end to end review of Nottingham City Council’s Adaptations and Occupational Therapy Services will be completed concentrating on the citizen journey through the whole system and will also consider resources, capacity and effective practice. This review will necessarily also address the sufficiency of resources in The Disabled Housing Advisor and the Occupational Therapy Services and make suitable recommendations regarding the maximisation of service capacity in order to meet demand.

The review will be, in part, informed by the Government commissioned Disabled Facilities Grant Review published in December 2018 as well as by the concerns raised in the Regulation 28. The working group will report directly to the Housing Strategy Group which is chaired by Catherine Underwood, DASS.

This review will focus on risk assessments completed for residents moving into Nottingham City Homes’ properties; however recommendations of the review as well as relevant information regarding changes implemented following its completion will be communicated effectively to the Adult Safeguarding Board in order that these can be shared with other social and private landlords. This action is key since Occupational Therapists will continue to assess the needs of and associated risks faced by disabled citizens living in privately rented housing in addition to social housing provided by other landlords and recommend suitable adaptations; however landlords are not obligated to complete recommended adaptations nor to permit Nottingham City Council to make these on their behalf.

Timeframe for planned action

The review will be completed by the beginning of October 2019. Implementation of all recommendations approved by the Housing Strategy Board and by Catherine Underwood, DASS, will commence in December 2019.

Report completed by:

Head of Integration, Adult Social Care Services Date: 22/03/2019

Report sections

Investigation and inquest

On 19 July 2018 an investigation was commenced into the death of Simon Paul Barber aged 49 years. The investigation concluded with an inquest on 17 January 2019.

The conclusion of the inquest was:

“Simon Paul Barber died on 18.07.18 at .

The medical cause of death is:

1a. Hypoxia due to smoke inhalation
2. Multiple sclerosis

Simon Paul Barber died as a result of a fire started by a naked flame coming into contact with his clothing. It is likely that naked flame was being used to light a cigarette and it is likely that the paraffin based cream used on Simon Paul Barber led to the fire growing quicker and burning more intensely.

The risk assessments that were carried out by care providers were inadequate, and there were missed opportunities to refer to Simon Paul Barber for a further home safety check.

An assessment of the bungalow for fire risks had not taken place”

Circumstances of the death

Simon Paul Barber was a gentleman who was wheelchair bound due to multiple sclerosis.

He moved from a flat to a bungalow on 11 July 2018.

He received care four times a day from First Class Care.

The inquest was assisted with evidence from the manager of First Class Care, Ms Mandy Leverton who said that during the assessment of needs performed by First Class Care, consideration was not given to how Simon Paul Barber would exit the property in an emergency.

The Court heard evidence that there was one ramp to the property, placed at the front door. At the side door into the kitchen were steps that Simon Paul Barber was unable to negotiate in his wheelchair.

The front door was locked with the key being in the key safe outside the address. The side door was open during the day and locked at night.

The risk to Simon Paul Barber of his continued use of cigarettes was not consid-ered. In 2012 a home safety assessment was carried out by the fire service and this found Simon Paul Barber was high risk due to his smoking habits. No further assessment was carried out despite his reduction in manual dexterity when han-dling cigarettes. Carers were using a paraffin based cream on Simon Paul Bar-ber and were not using the flame retardant blanket provided by the Fire Service in 2012.

In the days before he died, Simon Paul Barber dropped a lit cigarette in his lap causing a burn mark in his blanket. This incident was not reported by staff.

It was accepted by First Class Care their assessment had been inadequate

Action should be taken

In my opinion urgent action should be taken to prevent future deaths and I be-lieve you have the power to take such action.

Copies sent to

InterOthers sent copies for information1. CQC via email2. , Director for Adult Social Care, Loxley House, Station Street, Nottingham, NG2 3NG3. , Nottingham City Council, Loxley House, Station Street, Nottingham, NG2 3NG

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2019-0036
Date of report: 28 January 2019
Coroner: Tanyka Rawden
Coroner area: Nottinghamshire

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: 21 Jul 2019 (estimated).

Sent to

First Class Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.