Stephen Hunt

Coroner's concerns

AI summary

Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.

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(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment: In particular consideration should be given to: Duration of wears under breathing apparatus; Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances; Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal: Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately: Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU: (2) It is suggested that all FRSs should consider the implementation of measures to reduce the risks associated with the loss of communications at operational incidents. For example, to include safety control measures to ensure BA teams can be withdrawn from the risk area if needed.

(3) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training of the handing over and taking over of roles at incidents to ensure all the areas of information, including control measures, are captured and shared: (4) It is suggested that all FRSs should ensure that significant hazards and any safety control measures are the responsibility of the incident commander and should be recorded within each sector; to ensure visibility to all on the fireground, and passedlcopied for use by the the incident commanderlcommand team t0 assist on the analytical risk assessment: (5) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the appropriate use of thermal imaging cameras t0 include the limited extent t0 which can be relied upon to measure ambient temperature.

(6) It is suggested that all FRSs should undertake a_ review to ensure the adequacy of key safety they standard operating procedures, guidance and training in the deployment of aerial monitors to ensure the safety of any personnel within the risk area is not compromised: It is suggested that all FRSs should undertake a review to consider the circumstances in which inspections should be carried out under section 7(2)(d) of the Fire and Rescue Services Act 2004.

(8) It is suggested the above mentioned steps be undertaken jointly by Fire and Rescue Services and the FBU or other Health and Safety Representatives on the Health and Safety Committees.

(9) It is suggested that the Secretary of State for the Home Department considers measures t0 ensure that: fire risk assessors are adequately trained and qualified so as to be competent in the role, and the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor.

(10) It is understood that there are some 45 Fire and Rescue Services and the findings of the inquest need to be disseminated down to them all; The pressure is upon them to find their own solutions to problems against the backdrop of financial pressures. The Home Office now leads on fire issues and there has been ever increasing decentralisation. Whilst this is not without merit there appear t0 be difficulties in ensuring that services are meeting expectations and a means of disseminating national learning: It is suggested that consideration is given to able to mobilise a national and consistent approach to sharing the learning and testing So that it can be shown to be received, understood, actioned and embedded,

Responses

2 respondents

Devon Somerset Fire Rescue Service Fire & Rescue Service

8 Jun 2016 PDF

Noted

DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service. (AI summary)

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Hunt

PDF

Noted

The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme. (AI summary)

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RECEIVED Shailesh Vara MP Ministry 0 6 MAY 2016 Pasiareeotarystiader-Secretary of Justice Nigel S_ Meadows H.M; Senior Coroner AM Coroner's Office Your ref: 01632/2013 P.O; Box 532 MoJ ref: ADR32818 Manchester Town Hall Albert Square M6o 2LA 2s April 2016 Da_ n [a_6, INQUEST INTO THE DEATH OF STEPHEN HUNT, DECEASED Thank you for your letter of 30 March, addressed to the Lord Chancellor and Secretary of State for Justice , regarding the inquest you are holding into the death of the above named_ In particular; you raise the issue of legal aid funding for two individuals who you have identified as interested persons: am therefore replying as the Minister responsible for legal aid. have seen the recent judgment handed down by Mr Justice Leggatt; which confirmed that Article 6 of the ECHR was not engaged by the circumstances of this case and that the Director of Legal Aid Casework therefore had no power to make legal aid available to the two individuals via the legal aid exceptional funding scheme: also noted carefully the comments made regarding duty on coroners under the Coroners (Inquests) Rules 2013 to protect witnesses from self-incrimination. Under the legal aid scheme decided by Parliament as set out in the Legal Aid, Sentencing and Punishment of Offenders Act 2012, funding for representation at inquests is only available for family members in the form of exceptional case funding where, broadly, refusal t0 fund would breach Article 2 of the ECHR Or where the Director of Legal Aid Casework has made Wider Public Interest Determination in relation to the inquest and the family member. Under the scheme decided by Parliament; legal aid is not available for representation of non-family members and there are no current plans to change this scheme_ Finally, must point out that applications for legal aid are considered individually by the Legal Aid Agency and decisions are made by the Director or Legal Aid Casework independently of Ministers. The law does not allow Ministers to intervene. It is important that these decisions are, and are seen to free from political and Government influence 7- sex& (_Za V~ SHAILESH VARA T 020 3334 3555 E general queries@justice gsi gov.uk 102 Petty France F 0870 761 7753 Wgov.uklmoj London SWIH 9AJ the be,

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Investigation and inquest

In summary terms the jury found that the deceased had been unlawfully killed (by unlawful act manslaughter by arson) by a joint enterprise involving two juveniles and answered a number of other specific factual issues Narrative conclusion comprising the answers to the following questions: Question 1: you satisfied so that you are sure that the deceased was unlawfully killed by the acts of a single person? Answer: No Question 2: you satisfied so that you are sure that the deceased was unlawfully killed by the acts of a joint enterprise? Answer: Yes Question 3: Do you find that the fire was probably deliberately started by the acts of one person? Answer: No Question 4: Do you find that the fire was probably deliberately started by the acts of a joint enterprise? Answer: Yes May City: Are Are

Question 5: the caged cardboard storage area and the racking up the stairs the emergency exit doors probably installed in or about the summer of 2009? Answer: Yes Question 6: Was the caged cardboard storage area and the racking up the stairs from the emergency exit doors probably installed and in place on 2 August 2012 when a fire risk assessment was carried out and was it in place on 13 July 2013? Answer: Yes Question 7: Did the presence of the caged cardboard storage area and the racking up the stairs from the emergency exit doors contribute to the fire developing? Answer: Yes Question 8: This question asks you about the probable control measures that were in place during the afternoon shift on 13 July 2013:- (a): the period of wear for BA crews entering through the doorway in sector 1 probably limited to a period of time the shift? Answer: Yes (b) If the answer to the previous question is what was the time limit? Answer: Maximum 20 minutes (c) Were most BA crews entering through the doorway in sector probably told to remain at the top of the stairs just inside the doorway and fight the fire there only? Answer: Yes (d) Were there any other probable safety control measures instigated in sector 1 doorway for BA crews entering the building during the afternoon of 13 July 20132" Answer: Yes, there was a second officer to keep an eye on BA crews entering the doorway and to keep visual andlor verbal contact to check that they are okay: Question 9: the safety control measures that you have identified in response to question 8 probably communicated to: (a) The control officer who sent the deceased and into the building? Answer: No (b) The new sector commander for sector 1 at the changeover of shifts at about 2000 hours on 13 July 2013? Answer: Yes (c) The new entry control officer for sector 1 at the changeover of shifts at about 2000 hours on 13 20132" Answer: No Question 10: Were the same safety measures that you have identified in response to question 8 probably in place when the Deceased and his colleague entered the building and if not should they have been? Was from Was during day "yes" from safety Were entry July

Answer: Measures were in place although not implemented: These measures should have been carried through over handovers Question 11: Did the new sector commander andlor control officer for sector probably fail to understand or comprehend and then implement the measures were advised about? Answer: The new sector commander misinterpreted the brief and the entry control officer was not fully informed and, therefore, couldnt implement the safety measures Question 12: On or about the time the deceased and his colleague entered the building was either of the new Entry Control Otficer; the Sector Commander; the Sector Safety Officer, probably aware of the following:- (a) that the previous BA teams had been limited to a 20 minute wear? If So, please specify who (by reference to their role and not their name for example, Sector Commander; Entry Control Officer; Sector Safety Officer etc) knew what? Answer: Ops commander, Sector commander, Second safety officer, Ops support, Ops assurance and Sector officer (b) that had been directed to go to the top of the stairs and fight the fire at that point but go no further? If so, please specify who (by reference to their role and not their name for example, Sector Commander; Entry Control Officer; Sector Safety Officer; etc) knew what? Answer: Sector commander; BA entry control officer, second safety officer; incident commander; operations commander; operational support, operations assurance, sector officer, logistics officer, and sector 4 commander: (c) that a safety officer had been dedicated to watch over them and keep in communication? If so, please specify who (by reference to their role and not their name for example, Sector Commander; Control Officer; Sector Safety Officer; etc) knew what? Answer: Second safety officer, sector 1 commander, operations commander; operational support, sector safety officer, and sector 4 commander: Question 13 (a) What brief was probably given to the deceased and his colleague before entering the at 20.04 hours; and (b) had this brief changed from earlier briefs and, if SO, in what respectls? Answer: The deceased and his colleague were two briefs. The entry control officer gave:" Go to the top of the stairs, take over, sit there and squirt water, top of mezzanine, you know what the crack is". The second safety officer gave this quote "Go to the top of the stairs, turn left; turn right, use the thermal imaging camera , and spray water from there. The brief changed from earlier briefs due to the wording sorry, the brief changed from earlier briefs due to the wording with the inclusion of the word "mezzanine and no direct instructions Question 14: Did the deceased and his colleague probably follow their brief? Answer: they followed their brief as understood it: The confusion was due to use of the term "mezzanine and "seek out hot spots" may have led them to misunderstanding the brief Question 15: What factors probably contributed significantly to the death? They need not be the sole or even the_principal cause of_death_but they must be more than merely entry safety they: safety they safety Entry building the Yes, they the minimal: Answer:
1. Lack of communication information at handover
2. Lack of communication, information at briefing and debriefing
3. Misinterpretation of instructions
4. Incorrect decision making
5. Competency within roles given
6. Pauls Hair World storeroom layout; internal conditions (stock, debris, smoke detectors)
7. Breakdown of telemetry radio communications
8. Inadequate risk assessments
9. Inadequate fire safety measures within Paul's Hair World (Fire drills)
10. Act of vandalism criminal damage.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:

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