Julie Ann Camm

Coroner's concerns

AI summary

A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.

View full coroner's concerns

_ The Fire Service Report revealed that there were no smoke alarms fitted to the property This property was originally in the ownership of a Housing Association and it was established that there had been a partial re-wire, kitchen sockets only in 2008. Had it been due for a full re-wire then hard-wired smoke detectors would have been installed. The Housing Association's procedure at the time was to encourage their tenants t0 refer to the West Yorkshire Fire and Rescue Service to have a home fire safety check, but this was not in place when Miss Camm took out this tenancy: am aware that the Fire Service provide fire safety advice to all members of the community and will provide and fix smoke detectors free of charge where necessary: A considerable amount of work has been carried out to forge links with other agencies and provide them with education in risk identification with regard to fire safety_ The Fire and Rescue Service would encourage individuals or agencies to refer any member of the community to them, particularly those most vulnerable in the first instance through their local Fire Service. This property is now within the ownership of Leeds City council. Originally it was owned by a Housing Association Leeds West North West Homes_ The Council took over on October 2013. It is a matter of grave concern to me that there were no smoke detectors in the property, notwithstanding the vulnerability of Miss Camm as a tenant. therefore, recommend that the owner of this property inspect all their housing stock and arrange for either hard-wired detectors to be fitted at the earliest opportunity. Until this can be achieved further recommend that the landlord contact the West Yorkshire Fire and Rescue Service for home assessment teams to carry out the necessary assessment and, where appropriate, fit battery operated smoke detectors until such time as permanent hard-wired detectors can be installed, Had a smoke detector been in place, it is likely that neighbours and members of the public in the vicinity would have been alerted to the fire in sufficient time for Miss Camm to be rescued and her death could have been avoided.

Responses

1 respondent

Leeds City Council Local Authority / Fire Service

27 Feb 2014 PDF

Action Planned

Housing Leeds will install hard-wired smoke detection in 40 properties and battery-powered detectors in remaining properties without detection equipment over the next 12 months, in consultation with West Yorkshire Fire & Rescue Service. The Electrical Specification has been updated to include hard-wired detection for major electrical works, and the Annual Tenancy Visit will include smoke detection identification. (AI summary)

View full response

308 1/i2 Leeds SUIX cAywci Title of Report: Response to the Inquest into the Death of Julie Ann Camm Author: (contracts & Compliance Manager, Housing Leeds 33ix Date of Report: 27th February 2014 Reference: DH/EPS/3081/12 17 MAR 2344 Background, Investigation & Inquest "Julie Ann Camm was single lady aged 49 years, who suffered with schizophrenia causing her to have frequent auditory hallucinations There was no reference in her history to self-harm or suicide: On Tuesday 13th November 2012 at approx 03.45 hours, Julie was found in her smoke logged flat; 121 Latchmere Drive, Leeds 16. She had deliberately started a fire in the bedroom of her home and had also inflicted life threatening incised wounds upon herself with an electric knife: Her death was confirmed by Paramedics at 04.20 hours on 13th November 2012. The evidence does not support a view that Julie has deliberately taken her own life and nor was her death an accident: It is more likely that at the time her mental health had declined and she was responding to auditory hallucinations arising from her condition. Extract from the Coroner's Report into the death of Julie Ann Camm_ On 17*h January 2014 Housing Leeds received notification from David Hinchcliff, Senior Coroner; West Yorkshire (Eastern) inclusive of a Regulation 28 Report to Prevent Future Deaths in respect of the above case. The Report was made under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. A full copy of the Report can be found in Appendix A of this report: Coroner's Concerns The coroner has reported that there is a risk of future deaths owing to the fact that there were no smoke detectors fitted to the property: A partial re-wire had taken place in 2008, but no hard wired detection equipment installed, as per the existing Electrical Specification (in which hard-wired smoke detectors are only required to be installed as part of a full re-wire) The coroner reported that the absence of smoke detectors to be a matter of 'grave concern' that no smoke detectors were fitted to property, making specific reference to the vulnerability of Ms Camm; In the view of coroner; had smoke detectors been installed it is likely that neighbours and Ref; DHIEPSI3081/12 1 of 6 the the Page

Leeds C iT Y C 0 U N C / L members of the public in the vicinity would have been alerted to the fire in sufficient time for Ms Camm to be rescued and her death could have been avoided: Coroner' $ Recommendations _Irecommend that the owner of this property inspect all their housing stock and arrange for either hard-wired detectors to be fitted at the earliest opportunity: Until this can be achieved further recommend that the landlord contact the West Yorkshire Fire and Rescue Service for home assessment teams to carry out the necessary assessment and, where appropriate, fit battery operated smoke detectors until such time as permanent hard-wired detectors can be installed: Stock Condition Housing Leeds manages 52,441 properties in its role within Leeds City Council (LCC). Analysis of the LCC asset management system, Keystone has drawn the following data in relation to smoke detection equipment: Type of Detection No. of Properties % of Housing Stock Hard-Wired 36,108
68.85% Battery 6,130
11.69% Other* 352
0.67% None 9,851
18.78% Total 52,441
100.00% "Other' types of detection equipment primarily in sheltered accommodation and includes Warden Call: From the above data and in direct reference to the safety of our customers and the coroners concerns, the statistic from this data is the fact that some 18.78% of Housing Leeds properties do not contain any smoke detection equipment: It should be noted that this represents a 'worst case' in regard to this volume of properties with no smoke detection equipment as this does not account for smoke detection equipment installed by tenants or battery detection installed by West Yorkshire Fire and Rescue Service and these installation are not recorded on the Keystone system. Battery detection installation schemes have already been completed in 2013 in the West of the specifically targeting sheltered accommodation whereby battery detection and carbon monoxide detection equipment (where applicable) was installed in all sheltered dwellings with no existing detection equipment_ Additionally, following a fire to privately owned Caspon-type property in 2012, all properties of this construction type owned by LCC have had battery detection installed (where existing not present) in addition to the 'hot strike' completed by West Yorkshire Fire and Rescue Service following this fire. Both these programmes have been accounted for in the above data and recorded on Keystone. Ref: DHIEPSI3081/12

key city,

Leeds C !TY C 0 U N C /L Planned Programmes Response to Recommendations Leeds City Council and Housing Leeds are wholly committed installing hard-wired smoke detection equipment to 100% its properties. close, effective partnership has been forged between the former ALMO's (now merged together as Housing Leeds) via our Fire Safety Team and West Yorkshire Fire & Rescue Service. This partnership continues to grow with extensive consultation on matters such as the installation of a full sprinkler system in Marsden Court, Leeds 28; the first retro-fit sprinkler system of its kind in the Yorkshire Region. Additionally, West Yorkshire Fire & Rescue Service are currently delivering training programme to all Housing Managers and Sheltered Scheme Managers across Housing Leeds to raise awareness and allow for informed identification of hazards and risks, particularly in relation to vulnerable people. This training also provides further detail on West Yorkshire Fire & Rescue Services web-based referral process for vulnerable customers The training is expected to be completed by end March 2014 with & view to expanding this programme to other front line Officers in FY2014/15 Over the forthcoming 18 month period, hard-wired smoke detection equipment will be installed to all properties subject to fire risk assessment: Detection will be installed in high & low rise properties and will consist of a mains powered optical smoke alarm with rechargeable Iithium cells in the hallway and mains powered heat alarm with rechargeable lithium ells in the kitchen: This equates to some 1200 properties in the Housing Leeds region with a programme value of c EZOOk 4300 dwellings in Sheltered Housing Complexes and Sheltered Housing Dispersed Schemes citywide are also to receive smoke detection equipment via the CareRing system in FY2014/15 in €1.3m project: Additionally, E2.55m has been allocated to full re-wire of dwellings in the Housing Leeds for FY 2014/15. This equates to the re-wiring of around 1100 properties and will include the installation of hard-wired smoke detection equipment in all cases. Additional programmes of this nature are also secured for the other regions of Housing Leeds_ The properties have been selected for inclusion in the re-wire programme based on the findings of the latest Electrical Periodic Inspection. As a result, the overwhelming majority of these properties will not have existing hard-wired detection, owing to the age of the installation. The programme is set to run from April 2014 to March 2015 and follows a similar programme in FY 2013/14_ Furthermore, an additional E1OOk of has been ring-fenced for full rewires between March 2014 and April 2014. Housing Leeds is currently identifying which properties will benefit from this programme, anticipated to be in the region of 40 properties Again, this work will include the installation of hard wired smoke detection equipment in all cases_ Of the remaining properties with no smoke detection equipment, Housing Leeds plan to install; as a minimum, battery detection equipment over the next 12 month period: This will be done in consultation with West Yorkshire Fire & Rescue Service to produce an efficient; coherent and targeted plan: Ref: DHIEPS/3081/12

funding funding

Leeds CiTY C 0 U N C | L It is anticipated that current trajectory level of funding will remain largely consistent in these areas for the next 3-5 years, at which point Housing Leeds anticipate in cxcess of 95% of its properties will benefit from hard-wired smoke detection equipment, the remaining being protected by battery detectors_ The Electrical Specification issued to contractors operating for and on behalf of Housing Leeds is presently fully reviewed and, where applicable, updated. can confirm that part of this updates includes for the installation of hard-wired smoke detection in the event that any major electrical works are completed within the dwelling: This replaces the existing document which specifies the installation of hard-wired detection equipment as part of a full re-wire only_ As part of its commitment to delivering a customer focused service, Housing Leeds targets to visit 100% of customers in their homes on an annual basis This visit is kncwn as the Annual Tenancy Visit and focusses on number of areas, including vulnerability, safeguarding and compliancy with statutory inspections (for example the annual gas safety visit) With effect 1st April 2014, the Annual Tenancy Visit will now include the identification of smoke detection equipment In cases where smoke detection is not present, these properties will be referred to West Yorkshire Fire & Rescue Service for provision of smoke detectors until such time that hard wired detection equipment is provided: Ref: DHIEPSI3081/12

and being

Report sections

Investigation and inquest

Julie Ann CAMM; aged 49 years_ born 10 February 1963. The investigation concluded at the end of the inquest on 18 December 2013_ The conclusions of the inquest were by Narrative, which was: Julie Ann Camm was a single lady aged 49, who suffered with schizophrenia causing her to have frequent auditory hallucinations_ There was no reference in her history to self-harm or suicide On Tuesday 13 November 2012 at approximately 03.45 hours Julie was found in her smoke logged flat; 121 Latchmere Drive, Leeds 16. She had deliberately started a fire in the bedroom of her home and had also inflicted life threatening incised wounds upon herself with an electric knife. Her death was confirmed there by Paramedics at 04.20 hours on 13 November 2013. The evidence does not support a view that Julie has deliberately taken her own life and nor was her death an accident It is more likely that at the time her mental health had declined and she was responding to auditory hallucinations arising from her condition. 1(a) Carbon monoxide poisoning Multiple incised wounds

Circumstances of the death

Julie Ann Camm was a single lady aged 49 who was not in employment and who was late of 121 Latchmere Drive, Leeds 16_ Miss Camm suffered from mental health issues was diagnosed with schizophrenia She has previously been the subject of Sections pursuant to the Mental Health Act and there is reference in her history to her setting fires in the street but no previous mention of self-harm . Miss Camm was last seen alive by her family on 11 November 2012 and efforts to contact her thereafter proved futile but this was not unusual: At 04:10 hours on Tuesday 13 November 2012 the Emergency Services were contacted to the report of a fire at her address On arrival of the Fire and Ambulance Service_ (1) and was discovered that Miss Camm was dead on the landing of the property. She was found with deep cuts to her wrist; calf and throat The fire had been started by a naked in the bedroom that had been left smouldering_ The house was secured from within. Miss Camm's death was confirmed by Paramedics at that location at 04.20 hours on 13 November 2012_ There was a detailed Police enquiry revealing there to be no suspicious circumstances A Fire Service investigation concluded that the fire was started deliberately by the application of a naked flame to bed linen in the bedroom_

Action should be taken

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

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links