I was interested to read the Report for the Prevention of Future Deaths (PFD) issued by the Senior Coroner for Hertfordshire to Michael Gove MP in his role as Secretary of State for Levelling Up, Housing and Communities. The Report was issued following the tragic deaths of Daphne Holloway and Ivy Spriggs who died as a result of a fire at their residential care home. The coroner expressed two concerns: 

  1. That sprinkler systems are not a mandatory requirement for care homes whose occupants have either limited or no independent mobility and are therefore at higher risk from fire.
  2. That care homes whose occupants have either limited or no independent mobility, and are therefore at higher risk from fire, are not deemed to be ‘higher risk buildings’ (HRBs) unless they are at least 18m in height or at least 7 storeys high.

A coroner has a duty to issue a PFD Report where they consider a significant risk exists which if action is not taken could lead to further deaths. The coroner will issue the Report on the individual/organisation with the power to take the necessary action and that individual/organisation must write to the coroner within 56 days to specify what  action (if any) they will take/have taken to address the coroner's concerns.

The coroner's concerns come at a point where fire safety is receiving increasing focus in the care sector (the CQC's Memorandum of Understanding with the National Fire Chief's Council and the recent BUPA prosecution (see my blog here) are just two examples). We have also commented on the scope of the Building Safety Bill as drafted in excluding care homes in occupation (see here). 

We have seen recommendations from coroners provoke significant change (for example, the introduction of Natasha's law regarding food allergens), perhaps this report will drive a review of building and fire safety arrangements in the care sector?