Source · Prevention of Future Deaths

Emma Waring

Ref: 2015-0383 Date: 22 Sep 2015 Coroner: Simon Nelson Area: Manchester (North) Responses identified: 1 / 1 View PDF

The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.

Date 22 Sep 2015
56-day deadline 17 Nov 2015 est.
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.
View full coroner's concerns
Immediate and positive consideration of the compulsory inclusion in the design, planning and building phases for residential properties (especially for those properties housing vulnerable individuals) of Automatic Water Suppression Systems more commonly known as ‘domestic sprinklers’ so as to provide further safeguards in the event of accidental or indeed deliberate fires in such premises.

Responses

1 respondent
RBH
PDF
Action Taken

Rochdale Boroughwide Housing has delivered domestic sprinklers in properties occupied by some of their most vulnerable tenants and is working with Rochdale Council’s Strategic Housing Service on a project designed to offer additional support to those identified as hoarders. (AI summary)

View full response
Dear Sir Our Ref: Date: 22ndJune 2016

In addition, all RBH properties are fitted with hard-wired smoke detection in line with current legislation. Although a number of our properties fall under the auspices of the FS(RRO)2005, the property in which Miss Waring was resident (and the vast majority of those we manage) was not covered by any enforceable fire safety legislation. We none the less take the issue of fire safety extremely seriously and, as such entered into a formal Service Level Agreement with Greater Manchester Fire and Rescue Service in August 2013 for the joint provision of Safe & Well visits to all our tenants. These visits are offered regardless of circumstance however, due to resource implications for both organ isations they are presently targeted toward those considered to be most ‘at risk’ from fire due to their vulnerability in whatever regard that is evidenced. The visits are by self, RBH or partner agency referral and are undertaken by specific appointment chosen by the recipient themselves subsequent to which we jointly act upon any recommendations that are forthcoming including the potential onward referral to a number of partner agencies should additional support be identified. All visits and any actions taken by the agencies concerned are recorded by our Fire Safety Consultant who acts as our Single Point of Contact for this initiative and any personal information is shared in line with a formal Information Sharing Agreement with Greater Manchester Fire and Rescue Service signed by both parties in December 2013 via a secure electronic system. We are also currently working with Rochdale Council’s Strategic Housing Service on a project designed to offer additional support to those identified as hoarders, an issue which has become more prevalent over recent years. The intention of the project is not only to ensure a consistent approach across all housing providers here in Rochdale but also to ensure that all RBH staff have the necessary support to deal with such issues as and when they are identified. The ‘toolkit’ is based on the internationally recognised ‘Clutter Image Rating Scale’ which is also used by several other partner agencies not only here in Rochdale but across Greater Manchester as a whole. Regardless of all of the above, we will continue to seek new and innovative ways of delivering both our statutory fire safety duties and those which whilst not mandatory, we consider to be integral to our desire to be a housing provider of choice and to offer our tenants the best possible protection from fire. Although on occasion and despite our very best efforts tragic incidents such as that involving Miss Waring have the potential to occur, we are absolutely committed to continuous improvement and determined that any relevant lessons be learnt in our earnest attempts to ensure we do the very best that we can for all our tenants. I sincerely hope that the above information will prove useful to the outcome of your inquest and assure you of our very best attention at all times.

Report sections

Investigation and inquest
On the 12th of March 2015 I commenced an investigation into the death of Emma Waring for whom the cause of death was given as being that of 1a inhalation of the products of combustion. At the inquest on 17 September 2015 the conclusion was one of an ‘accidental death’.
Circumstances of the death
Emma Waring was 23 years old at the time of her death. She was working with a family support worker as a result of her 2 year-old son having been taken into care 8 months previously. She was known to be a heavy drinker and cigarette smoker and was by all accounts a vulnerable individual.. She moved into her rented accommodation in July 2014 and as with similar dwellings in the immediate vacinity it had been fitted with ‘hard wired’ smoke alarms by Rochdale Boroughwide Housing. The evidence at inquest indicated that the fire had started at some time after 01:50 hours on 7 March 2015; the smoke alarm activated and would have been audible to neighbours. However the initial call to the emergency services was not made until 02.40 hours. It was more likely than not that a cigarette had come into contact with bedding materials and that whilst the deceased was asleep the fire had developed filling the bedroom with toxic smoke. At some point the deceased had became aware of the fire, possibly due to the smoke detectors operating, and had attempted to escape but had been quickly overcome by the toxic products of combustion designated Community Safety Manager with the Greater Manchester Fire and Rescue Service confirmed in evidence that the Service ‘strongly advocated the installation of domestic automatic water suppression systems (sprinkler systems) and that had such a system been installed in the deceased’s home then the chances of her surviving this fire would have been significantly increased
Copies sent to
2. Greater Manchester Fire and Rescue Service3. Rochdale Boroughwide Housing

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Report details

Reference
2015-0383
Date of report
22 September 2015
Coroner
Simon Nelson
Coroner area
Manchester (North)

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: 17 Nov 2015 (estimated).

Sent to

Department for Communities and Local Government

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