Lorraine Karat
PFD Report
All Responded
Ref: 2021-0364
All 1 response received
· Deadline: 24 Dec 2021
Sent To
Response Status
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56-Day Deadline
24 Dec 2021
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Clarion Housing is the company from which Lorraine Karat rented her flat. There are 17 flats in the building, in a complex for the over 55s. All residents have been nominated for occupation by the local authority.
Clarion is responsible for the fabric of the building. The property is staffed by a Clarion building manager/concierge who undertakes fire and health & safety checks, and may assist residents in reading correspondence and so forth. There is no restriction on visitors, including children.
1. No evidence was provided at inquest of a risk assessment having been undertaken of Ms Karat’s flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat.
2. I was told by Clarion’s group health, safety and wellbeing manager at inquest, that the building manager did not know that there had been any unauthorised use of the balcony. However, the manager did not enter the flat to check, nor was there any evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy.
3. The balcony was not contained by a railing or other structure to make it safe for use.
4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony.
5. I do not know whether this situation is replicated in other Clarion properties. Wikipedia describes Clarion as the largest housing group in the UK, with 350,000 properties across 170 local authorities.
Clarion is responsible for the fabric of the building. The property is staffed by a Clarion building manager/concierge who undertakes fire and health & safety checks, and may assist residents in reading correspondence and so forth. There is no restriction on visitors, including children.
1. No evidence was provided at inquest of a risk assessment having been undertaken of Ms Karat’s flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat.
2. I was told by Clarion’s group health, safety and wellbeing manager at inquest, that the building manager did not know that there had been any unauthorised use of the balcony. However, the manager did not enter the flat to check, nor was there any evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy.
3. The balcony was not contained by a railing or other structure to make it safe for use.
4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony.
5. I do not know whether this situation is replicated in other Clarion properties. Wikipedia describes Clarion as the largest housing group in the UK, with 350,000 properties across 170 local authorities.
Responses
Clarion Housing Group disputes that the flat roof was intended as a balcony and that they had the right to enter, and notes the facility is closing. However, they have developed a "Flat roof Safety Plan," issued "Dangers of Flat Roofs" guidance to residents and staff, and instructed staff to identify other flat roofs with potential unauthorised access to implement additional controls like window restrictors where risks are identified.
AI summary
View full response
In the Inner North London Coroners Court Inquest touching the death of Lorraine Karat Response by Clarion Housing Group to the PFD report issued by HM Senior Coroner M.E.Hassell dated
29.10.2021 The Coroner’s concerns:
1. No evidence provided at the inquest of a risk assessment having been undertaken on Ms Karat’s flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat. Response: Where CHG become aware of specific risks arising in relation to its tenants then risk assessments of flats will be carried out following CHG’s internal safeguarding process which may involve other stakeholders. If concerns are identified by or brought to the attention of CHG then appropriate steps would be taken on a risk-based approach basis.
2. The building manager did not know of unauthorised use of the balcony and did not enter the flat to check, nor was there evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy. Response: Where Ms Karat lived the flats are the tenants’ private property. There is no right for CHG to enter a flat on a random basis to check if tenants might be accessing a balcony and absent specific information reaching CHG there would be no reason to ask a tenant if they were accessing a flat roof. To try and avoid the possibility of a similar situation arising at any other facility CHG are running a process to inform tenants that where there are flat roofs to which access might be possible this is neither authorised nor a safe activity. CHG have developed the attached “Flat roof Safety Plan” which sets out the items in hand which seek to address the Coroner’s concerns. This is a living document and will be reviewed and updated as information is received. The attached “Dangers of Flat Roofs – Guidance for our residents” document which is now available in the tenants’ customer facing website area
displayed in common parts in facilities where relevant flat roofs exist as well as tenants being provided this information. This information will be conveyed to new tenants in relevant buildings as part of the tenancy agreement sign up procedure. To ensure that staff are aware of the risks arising from unauthorised flat roof access CHG are issuing guidance to staff as shown in the attached “Dangers of flat roofs – Guidance for staff”. This document instructs staff across the CHG sites to identify any flat roofs where unauthorised access might occur and to engage with the CHG safety team to assess what steps need to be taken to prevent access being gained to the flat roof.
3. The balcony was not contained by a railing or other structure to make it safe to use. Response: CHG did not intend the flat roof to be accessed and used by anyone and were unaware that Ms Karat was accessing it. If it had been the intention of CHG that the tenant was allowed to access the flat roof, then appropriate measures would have been taken to provide railings in compliance with Building Regulations. The two flats at the facility where Ms Karat was living are no longer occupied and will not now be used as the facility is in the process of being wound down for eventual closure.
4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony. Response: As noted in the action plan additional controls are now being deployed where flat roofs have been identified as posing a significant risk of access from a tenanted property. Additional measures such as window locks and restrictors can be installed where a risk of unauthorised access to a flat roof has been identified and a risk assessment indicates that for a particular tenant that measure should be deployed.
5. I do not know whether this situation is replicated in other Clarion properties. Response: As noted in the Flat Roof action plan CHG are ensuring, by way of engaging Housing Teams and other key operational teams, that flat roofs with potential unauthorised access are identified and relevant action taken. Clarion Housing Group 17 January 2022
29.10.2021 The Coroner’s concerns:
1. No evidence provided at the inquest of a risk assessment having been undertaken on Ms Karat’s flat, most especially including the window that opened over a metre high onto the balcony, thereby rendering the balcony accessible from within the flat. Response: Where CHG become aware of specific risks arising in relation to its tenants then risk assessments of flats will be carried out following CHG’s internal safeguarding process which may involve other stakeholders. If concerns are identified by or brought to the attention of CHG then appropriate steps would be taken on a risk-based approach basis.
2. The building manager did not know of unauthorised use of the balcony and did not enter the flat to check, nor was there evidence that Ms Karat had actually been told that use of the balcony was not authorised, still less been asked about this during her tenancy. Response: Where Ms Karat lived the flats are the tenants’ private property. There is no right for CHG to enter a flat on a random basis to check if tenants might be accessing a balcony and absent specific information reaching CHG there would be no reason to ask a tenant if they were accessing a flat roof. To try and avoid the possibility of a similar situation arising at any other facility CHG are running a process to inform tenants that where there are flat roofs to which access might be possible this is neither authorised nor a safe activity. CHG have developed the attached “Flat roof Safety Plan” which sets out the items in hand which seek to address the Coroner’s concerns. This is a living document and will be reviewed and updated as information is received. The attached “Dangers of Flat Roofs – Guidance for our residents” document which is now available in the tenants’ customer facing website area
displayed in common parts in facilities where relevant flat roofs exist as well as tenants being provided this information. This information will be conveyed to new tenants in relevant buildings as part of the tenancy agreement sign up procedure. To ensure that staff are aware of the risks arising from unauthorised flat roof access CHG are issuing guidance to staff as shown in the attached “Dangers of flat roofs – Guidance for staff”. This document instructs staff across the CHG sites to identify any flat roofs where unauthorised access might occur and to engage with the CHG safety team to assess what steps need to be taken to prevent access being gained to the flat roof.
3. The balcony was not contained by a railing or other structure to make it safe to use. Response: CHG did not intend the flat roof to be accessed and used by anyone and were unaware that Ms Karat was accessing it. If it had been the intention of CHG that the tenant was allowed to access the flat roof, then appropriate measures would have been taken to provide railings in compliance with Building Regulations. The two flats at the facility where Ms Karat was living are no longer occupied and will not now be used as the facility is in the process of being wound down for eventual closure.
4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony. Response: As noted in the action plan additional controls are now being deployed where flat roofs have been identified as posing a significant risk of access from a tenanted property. Additional measures such as window locks and restrictors can be installed where a risk of unauthorised access to a flat roof has been identified and a risk assessment indicates that for a particular tenant that measure should be deployed.
5. I do not know whether this situation is replicated in other Clarion properties. Response: As noted in the Flat Roof action plan CHG are ensuring, by way of engaging Housing Teams and other key operational teams, that flat roofs with potential unauthorised access are identified and relevant action taken. Clarion Housing Group 17 January 2022
Report Sections
Investigation and Inquest
On 25 June 2021, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Lorraine Karat, aged 68 years. The investigation concluded at the end of the inquest on 25 October 2021. I determination made at inquest of accidental death. The medical cause of death was: 1a multiple injuries 2 recent alcohol use.
Circumstances of the Death
Lorraine Karat fell from a second floor balcony outside her flat, possibly in her sleep. She had been drinking heavily. The balcony parapet was only 36cms high and not contained by any railing. One of her sons had warned her that it was dangerous for her to go out there, but she did sleep on the balcony on warm nights.
The housing company from which she rented her flat did not intend the balcony to be used by the resident of the flat. However, there is no evidence that the company ever told her this, and there was no warning sign. There were no bars on the window that she had used to access the balcony, nor were there any window restrictors.
The housing company from which she rented her flat did not intend the balcony to be used by the resident of the flat. However, there is no evidence that the company ever told her this, and there was no warning sign. There were no bars on the window that she had used to access the balcony, nor were there any window restrictors.
Copies Sent To
, director of housing mgt, Camden Council
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.