Source · Prevention of Future Deaths

Ian Leak

Ref: 2017-0274 Date: 15 Aug 2017 Coroner: Alison Mutch Area: Manchester (South) Responses identified: 1 / 2 View PDF

The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with mobility problems under a "Stay Put" policy.

Date 15 Aug 2017

56-day deadline 10 Oct 2017

Responses identified 1 of 2

Other related deaths

Coroner's concerns

AI summary

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The MATTERS OF CONCERN as follows: I heard evidence that Honiton Oaks was, at all material times , equipped with two fire alarm systems, both of which appear to have operated as intended in this case The first fire alarm system detects heat and or smoke in communal areas and, if triggered,opens glass smoke vents and deactivates the lift having returned it to the from his are ground floor: In accordance with the 'Stay Put' policy currently in operation of Honiton Oaks, whilst this system creates a visual alert on a fire control panel within the building, it does not trigger an audible fire alarm which other residents can hear The second system consists of combined heat ad smoke detectors fitted in tenants' individual flats_ These generate an audible warning within the individual flat where the detectors have been triggered, but operates independently of the system covering the communal areas_ In the course of the inquest, heard that as a result of planned upgrades to the Honiton Oaks alarm systems, from the end of this month, the communal system will be linked to an external monitoring service in addition to the internal panel: also heard evidence to the effect that Mr Leak was not the only tenant with mobility problems who resided at Honiton Oaks In such circumstance, in the light of the building's Put' policy, consideration should be given in the case of tenants who have particular mobility problems or are otherwise likely to have difficulty in escaping from a fire within the confines of their own flat, to arranging for external monitoring of the individual fire alert systems within those tenants' flats_

Responses

1 respondent

Peak Valley Housiing Asscoiation Other

PDF

Action Planned

The housing association is installing combined heat and smoke detectors in residents' flats, linked to a main system with external monitoring, commencing in October 2017. They have also commenced a wider review of fire safety across the Onward Homes portfolio, including their approach to vulnerable residents. (AI summary)

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Dear Mr Moris_ Regulation 28 Report 6820/CH Thank you for your Regulation 28 Report dated 154 August 2017 , which oullined the tragic circumslances of this incident: The safety of our customers is our highest priority and we operate clear fire safety procedures to ensure we comply wilh current legislation and keep our customers safe. Honilon Oaks Is a relatively new building, constructed in accordance with building regulalions and following receipt of your report we have met with Ihe local fire authority t0 explore and review a range of potential options. We understand lhe concerns raised in your report relate to the ability of some residenls lo ralise the alam in the event of a fire incident; where a put' policy operates can advise that we agree wllh your recommendations and are proposing to undertake the following actions as a result of this case. We have been working with specialists and have approved the design for improvements to Ihe existing fire alarm syslems within Honiton Oaks. The design includes the inslallation of combined heat and smoke detectors to residents' {lats , linked to main system, which will provide early warning t0 all residents within Honiton Oaks. The system will operale with exlernal moniloring and the work is programmed to commence during Oclober 2017. As a result of Ihe tragic fire at Grenfell; we have also commenced a wider review of fire safety across the Onward Homes portfolio. As part of this review we will look specifically at our approach to vulnerable residents to ensure we minimise potentlal risks. We are aware a national review of building regulations has commenced, which includes fire safety and we continue to monitor developments. Reglstered Olika The Hub Srckpan Aoad Mottram Hyde SK14 6AF Peak Varoy Husng Assoclatkon eolstaled wth the Homes and Communitlet Agoncy (No 4475 I Peak Valay Houslng Assocation /s roglslerd socialy under Ina Co-oparattve and Communty Benelt Socellas Act 2014 (No_29311a) Par ol Onward Homes Disae "stay the

Tho Hub Stockpon Aoad Mattam Hyde SK14 6AF Peak Valley Tel 0345 270 3501 Fax 0161 882 9840 HOUSING ASSOCIATION Wam pvha CO uk Emall mail @pvha co uk If you require any addilional information please do not hesllate t0 contact me:

Report sections

Investigation and inquest

On 25"h April 2017 , Alison Mutch OBE, Senior Coroner for Manchester South; commenced an investigation into the death of Ian Leak who was aged 59 when he died at his home address on 5"h March 2017.The investigation concluded on the 10"" August 2017 . The conclusion of the inquest was that Mr Leak died as a consequence of a fire in his flat, which was likely to have been started by a lit cigarette coming into contact with combustible material. At the end of the inquest; recorded a conclusion of Accident The medical cause of death was 1a) Fire Related Death II) Ischaemic Heart Disease:

Circumstances of the death

Mr Leak had suffered very poor health for a number of years Having been diagnosed with a brain tumour, he endured some 15 brain operations, and experienced a number of strokes As a result; Mr Leak was left with significant disabilities. He had serious mobility problems, ad memory was affected. He could also become confused. Mr Leak was a tenant at Peak Housing's Honilon Oaks property, where he had his own flat; On Sth March 2017 , the fire service was alerted t0 a fire at Mr Leak's flat. The flat was entered and Mr Leak was tragically found to have died

Action should be taken

In my opinion action should be (aken t0 prevent future deaths and believe you have the power to take such action.

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Report details

Reference: 2017-0274
Date of report: 15 August 2017
Coroner: Alison Mutch
Coroner area: Manchester (South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Oct 2017.

Sent to

Peak Valley Housing Association

Hub

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.