Brian MaClean
PFD Report
Partially Responded
Ref: 2017-0223
1 of 2 responded · Over 2 years old
Response Status
Responses
1 of 2
56-Day Deadline
6 Nov 2017
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased. This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS.
2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.
3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits.
4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed.
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
2. There was no identification of the deceased as being potentially at risk of a fire in his premises and no referral to GMFRS.
3. There was no process for GPHA to automatically consider fire risks and prevention and make referrals to GMFRS for safe and well visits.
4. It is clear that GPHA did not have an automatic water suppression system (sprinklers) that could be fitted to properties which comprise blocks of flats and or for individuals at high risk. In addition appropriate smoke alarms and other assistive technology could have been installed.
5. The recipients of this report would be well advised to read and digest the detailed GMFRS Fire Investigation Report and its recommendations which are wholly endorsed by the court.
Responses
Response received
View full response
Nigel S. Meadows - H.M. Senior Coroner H.M Coroner’s Office PO Box 532 Manchester Town Hall Albert Square M60 2LA
Adult’s Social Services
Manchester City Council P.O Box 532 Town Hall Manchester M60 2LA Date: 6th November 2017
Dear Mr Meadows,
Report to HM Coroner Mr Nigel Meadows in response to the Regulation 28 Report
Dated 11 September 2017
Subject: Brian Maclean (d.o.b 20/12/1957), ,
Background
Mr Maclean died in a fire at his home on 19 March 2016. He lived alone and was known to
have a long standing alcohol abuse and health problems. On the day of his death, it is
understood Mr Maclean had consumed a significant amount of alcohol and had caused a fire.
A Fire and Rescue Report by Greater Manchester Fire and Rescue Service's (GMFRS)
identified the likely cause of the fire to have been “carelessly discarded smoking materials”.
The Coroner concluded the inquest into the death of Mr Maclean on 6 September 2017 and
recorded that he died from smoke inhalation contributed to by alcohol toxicity. A conclusion
of “alcohol related” was recorded.
The Coroner identified a number of areas of concern in a Regulation 28 Report to Prevent
Future Deaths including: “That Social Services did not take a more proactive role in pursuing
any referral and understanding the risks presented by the deceased. This requires joined up
thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS.”
The Coroner directed that action be taken to prevent future deaths, such response to contain
details of action taken or proposed to be taken and to set out the timetable for action or,
alternatively, to explain why no action is proposed.
Response on behalf of Manchester City Council
A referral was made via an online form to Manchester City Council’s (MCC) Contact Centre
for Children, Families and Adult Social Care on 26 January 2016 by Mr Macleans support
worker from Great Places, a housing provider.
The Contact Centre acts as the initial point of contact for all queries, concerns and referrals
raised in connection with a child or adult at risk.
The referral expressed concerns about Mr Maclean’s living conditions, personal hygiene,
levels of nutrition, mental capacity and rent arrears.
The referral was read and prioritised as 'not urgent' by a Customer Service Officer (Officer A)
on the 26 January 2016. This referral was subsequently placed into a non-urgent folder to be
processed.
On 12 February 2016 another Customer Service Officer (Officer B) was allocated the referral
and began processing it that day. Officer B contacted the referrer (Great Places) to request
the GP details of Mr Maclean and to request the referrer contact him back when Mr Maclean
was present to enable him to speak to the gentleman as there was no telephone number for
Mr Maclean on the referral. This was to enable Customer Services to establish further
information and to gain consent from Mr Maclean.
An email was subsequently received from the support worker from Great Places on the 17
February 2016 with the GP details for Mr Maclean. Officer B then contacted Mr Maclean's GP
on the 19 February 2016 to establish Mr Maclean's health condition and his capacity to
consent to the referral. Following the discussion with Mr Maclean's GP Officer B took the
decision to take no further action in respect of the referral. Officer B subsequently recorded
onto the electronic recording system: “no consent/concerns not substantiated by GP/NFA.
Letter sent.”
The letter to Mr Maclean stated that contact has been received from Great Places to advise
that he may need support, that an officer had attempted to contact Mr Maclean to gather
further information without success and Mr Maclean should contact the service again should
he wish to access services in the future.
Findings of the management investigation
Following the concerns raised by the Coroner a management investigation has taken place.
It is evident from the investigations of the actions taken by Officers A and B that internal
procedures were not followed.
Based on the information provided by the referrer the original officer, Officer A, who classified
the referral should have identified that an urgent response was required and it should have
been placed into the urgent folder to be processed immediately. The concerns expressed in
the referral meet the criteria for urgent action in that Mr Maclean was clearly eligible for an
assessment under the Care Act and potentially at risk of significant harm.
Officer A’s conduct is currently being addressed through MCC disciplinary procedures.
Based on the information provided in the referral by the referrer in respect of Mr Maclean the
second officer, Officer B, should have passed it to the Primary Assessment Team for further
assessment once he had established that he was unable to make contact. The referral also
indicated consent had in fact been received from Mr Maclean.
Officer B’s conduct is also being addressed through MCC disciplinary procedures and the
officer is currently on alternative duties
Actions
In response to the concerns raised by the Coroner and the outcome of the management
investigation the following actions have taken place or are to be taken:
1. All contacts which have been closed or viewed as non-urgent by Officers A and B
have been reviewed.
2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact
Centre between July 2017 and September 2017 is being undertaken
3. Further training will be provided for all Contact Centre staff in respect of the Care Act,
safeguarding and consent. This will be arranged immediately and will be provided by
MCC’s Quality Assurance Team.
4. The Quality Assurance Team are to undertake regular audits of the work undertaken
by the Contact Centre.
5. MCC is currently exploring increasing social work supervision and oversight of the
Contact Centre officers
6. MCC has considered the recommendations of the GMFRS report and will continue
with the work currently underway to raise the awareness of the services offered by
GMFRS among adult social care staff. There are regular meeting between the
Community Safety Officer from GMFRS and MCC to ensure that all options for
extending partnership working are considered.
7. MCC will be referring this matter to Manchester Safeguarding Adults Board for their
consideration as to whether this meets the criteria for a Safeguarding Adults Review.
Yours sincerely,
Deputy Director of Adult’s Social Service - Manchester City Council
Adult’s Social Services
Manchester City Council P.O Box 532 Town Hall Manchester M60 2LA Date: 6th November 2017
Dear Mr Meadows,
Report to HM Coroner Mr Nigel Meadows in response to the Regulation 28 Report
Dated 11 September 2017
Subject: Brian Maclean (d.o.b 20/12/1957), ,
Background
Mr Maclean died in a fire at his home on 19 March 2016. He lived alone and was known to
have a long standing alcohol abuse and health problems. On the day of his death, it is
understood Mr Maclean had consumed a significant amount of alcohol and had caused a fire.
A Fire and Rescue Report by Greater Manchester Fire and Rescue Service's (GMFRS)
identified the likely cause of the fire to have been “carelessly discarded smoking materials”.
The Coroner concluded the inquest into the death of Mr Maclean on 6 September 2017 and
recorded that he died from smoke inhalation contributed to by alcohol toxicity. A conclusion
of “alcohol related” was recorded.
The Coroner identified a number of areas of concern in a Regulation 28 Report to Prevent
Future Deaths including: “That Social Services did not take a more proactive role in pursuing
any referral and understanding the risks presented by the deceased. This requires joined up
thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS.”
The Coroner directed that action be taken to prevent future deaths, such response to contain
details of action taken or proposed to be taken and to set out the timetable for action or,
alternatively, to explain why no action is proposed.
Response on behalf of Manchester City Council
A referral was made via an online form to Manchester City Council’s (MCC) Contact Centre
for Children, Families and Adult Social Care on 26 January 2016 by Mr Macleans support
worker from Great Places, a housing provider.
The Contact Centre acts as the initial point of contact for all queries, concerns and referrals
raised in connection with a child or adult at risk.
The referral expressed concerns about Mr Maclean’s living conditions, personal hygiene,
levels of nutrition, mental capacity and rent arrears.
The referral was read and prioritised as 'not urgent' by a Customer Service Officer (Officer A)
on the 26 January 2016. This referral was subsequently placed into a non-urgent folder to be
processed.
On 12 February 2016 another Customer Service Officer (Officer B) was allocated the referral
and began processing it that day. Officer B contacted the referrer (Great Places) to request
the GP details of Mr Maclean and to request the referrer contact him back when Mr Maclean
was present to enable him to speak to the gentleman as there was no telephone number for
Mr Maclean on the referral. This was to enable Customer Services to establish further
information and to gain consent from Mr Maclean.
An email was subsequently received from the support worker from Great Places on the 17
February 2016 with the GP details for Mr Maclean. Officer B then contacted Mr Maclean's GP
on the 19 February 2016 to establish Mr Maclean's health condition and his capacity to
consent to the referral. Following the discussion with Mr Maclean's GP Officer B took the
decision to take no further action in respect of the referral. Officer B subsequently recorded
onto the electronic recording system: “no consent/concerns not substantiated by GP/NFA.
Letter sent.”
The letter to Mr Maclean stated that contact has been received from Great Places to advise
that he may need support, that an officer had attempted to contact Mr Maclean to gather
further information without success and Mr Maclean should contact the service again should
he wish to access services in the future.
Findings of the management investigation
Following the concerns raised by the Coroner a management investigation has taken place.
It is evident from the investigations of the actions taken by Officers A and B that internal
procedures were not followed.
Based on the information provided by the referrer the original officer, Officer A, who classified
the referral should have identified that an urgent response was required and it should have
been placed into the urgent folder to be processed immediately. The concerns expressed in
the referral meet the criteria for urgent action in that Mr Maclean was clearly eligible for an
assessment under the Care Act and potentially at risk of significant harm.
Officer A’s conduct is currently being addressed through MCC disciplinary procedures.
Based on the information provided in the referral by the referrer in respect of Mr Maclean the
second officer, Officer B, should have passed it to the Primary Assessment Team for further
assessment once he had established that he was unable to make contact. The referral also
indicated consent had in fact been received from Mr Maclean.
Officer B’s conduct is also being addressed through MCC disciplinary procedures and the
officer is currently on alternative duties
Actions
In response to the concerns raised by the Coroner and the outcome of the management
investigation the following actions have taken place or are to be taken:
1. All contacts which have been closed or viewed as non-urgent by Officers A and B
have been reviewed.
2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact
Centre between July 2017 and September 2017 is being undertaken
3. Further training will be provided for all Contact Centre staff in respect of the Care Act,
safeguarding and consent. This will be arranged immediately and will be provided by
MCC’s Quality Assurance Team.
4. The Quality Assurance Team are to undertake regular audits of the work undertaken
by the Contact Centre.
5. MCC is currently exploring increasing social work supervision and oversight of the
Contact Centre officers
6. MCC has considered the recommendations of the GMFRS report and will continue
with the work currently underway to raise the awareness of the services offered by
GMFRS among adult social care staff. There are regular meeting between the
Community Safety Officer from GMFRS and MCC to ensure that all options for
extending partnership working are considered.
7. MCC will be referring this matter to Manchester Safeguarding Adults Board for their
consideration as to whether this meets the criteria for a Safeguarding Adults Review.
Yours sincerely,
Deputy Director of Adult’s Social Service - Manchester City Council
Report Sections
Investigation and Inquest
I resumed and concluded the inquest into the death of Mr Brian MaClean on 6 September 2017 and recorded that he died from:
1a Smoke inhalation
II Alcohol toxicity
Somewhat unusually I recorded a conclusion of – Alcohol related
1a Smoke inhalation
II Alcohol toxicity
Somewhat unusually I recorded a conclusion of – Alcohol related
Circumstances of the Death
The deceased was born on 20 December 1957 and had developed over a number of years a significant alcohol consumption problem. He was also a regular smoker of cigarettes. He had lost touch largely with his family and had spent periods of time in private rented accommodation and more recently at a Salvation Army Hostel. He took up occupation of Flat 35 George Thomas Court, Harpurhey, Manchester, on 26 November 2012 and lived on his own.
This accommodation is owned by Great Places Housing Association (GPHA).
He was allocated a support worker who discovered that he had no telephone or access to email and was only ever intermittently available to see his support worker.
The deceased was not in employment and was in receipt of state benefits. It seems that a referral was made to the Manchester City Council Adult Social Services Department on 26 January 2016. His support worker had discovered that he had no household appliances other than a microwave in which he cooked all of his meals and had little in the way of possessions. He claimed to have a nursing background and a long term chronic bowel condition. This apparently resulted in the local authority writing a letter to the deceased asking if he required any help or support and when they received no reply the case was closed.
Greater Manchester Fire and Rescue Service (GMFRS) regularly work with housing providers to facilitate the referral of persons at increased risk of suffering a fire. No such referral was made in respect of the deceased.
The deceased was registered with a GP at the Singh Medical Practice but was an infrequent attender, but with a diagnosis of Chrohn’s Disease and a long term alcohol problem. The fire had self-extinguished.
On 19 March 2016 the deceased had consumed a very excessive amount of alcohol and had been smoking whilst sitting in his sofa. A fire started on the sofa which created a great deal of noxious smoke. It also caused him to suffer a burnt leg. When the alarm was raised and GMRFS attended he was found in the hall way having apparently made attempts to remove his trousers.
He died as a result of smoke inhalation contributed to by alcohol toxicity. All other sources of ignition for the fire apart from a discarded cigarette were ruled out.
The premises did not have an automatic water sprinkler system.
Statistically a significant proportion of fatal fires involve single males living on their own having drink, drugs or mental health problems. Since the incident GMFRS have worked with GPHA to deliver fire prevention staff awareness training and to introduce them to the new ‘Safe and Well Visits’ that GMFRS are now offering. A copy of the record of inquest and the evidence accompanies this report.
This report is being distributed to MCC Housing Department with a request that they consider it internally but also that they distribute it to all other Housing Associations within Greater Manchester. In addition to the NHS and the GP MPC.
This accommodation is owned by Great Places Housing Association (GPHA).
He was allocated a support worker who discovered that he had no telephone or access to email and was only ever intermittently available to see his support worker.
The deceased was not in employment and was in receipt of state benefits. It seems that a referral was made to the Manchester City Council Adult Social Services Department on 26 January 2016. His support worker had discovered that he had no household appliances other than a microwave in which he cooked all of his meals and had little in the way of possessions. He claimed to have a nursing background and a long term chronic bowel condition. This apparently resulted in the local authority writing a letter to the deceased asking if he required any help or support and when they received no reply the case was closed.
Greater Manchester Fire and Rescue Service (GMFRS) regularly work with housing providers to facilitate the referral of persons at increased risk of suffering a fire. No such referral was made in respect of the deceased.
The deceased was registered with a GP at the Singh Medical Practice but was an infrequent attender, but with a diagnosis of Chrohn’s Disease and a long term alcohol problem. The fire had self-extinguished.
On 19 March 2016 the deceased had consumed a very excessive amount of alcohol and had been smoking whilst sitting in his sofa. A fire started on the sofa which created a great deal of noxious smoke. It also caused him to suffer a burnt leg. When the alarm was raised and GMRFS attended he was found in the hall way having apparently made attempts to remove his trousers.
He died as a result of smoke inhalation contributed to by alcohol toxicity. All other sources of ignition for the fire apart from a discarded cigarette were ruled out.
The premises did not have an automatic water sprinkler system.
Statistically a significant proportion of fatal fires involve single males living on their own having drink, drugs or mental health problems. Since the incident GMFRS have worked with GPHA to deliver fire prevention staff awareness training and to introduce them to the new ‘Safe and Well Visits’ that GMFRS are now offering. A copy of the record of inquest and the evidence accompanies this report.
This report is being distributed to MCC Housing Department with a request that they consider it internally but also that they distribute it to all other Housing Associations within Greater Manchester. In addition to the NHS and the GP MPC.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.