Dear Miss Sharma Re: Jane BENNETT - DOB: 19/09/1970- DECEASED. Late of 23 Eather Avenue Mansfield Woodhouse, Mansfield, Nottinghamshire, NG19 8AY I refer to your recent Regulation 28 Report to Prevent Future Deaths dated 24 November 2023 in respect of Mrs Jane Bennett’s tragic death. Firstly, I would like once again to express my deepest condolences, and those of the council, to the family of Mrs Bennett. This response seeks to provide the Coroner with assurance that Mansfield District Council takes its role as landlord and the health and wellbeing of our tenants extremely seriously. The Regulation 28 report details the matters of concern being that mould in Mrs. Bennett’s property and other properties in that area owned and maintained by Mansfield District Council may pose a risk that future deaths could occur. You asked for the aforesaid properties to be inspected for mould and action be taken to ensure any further exposure to mould by any tenant is minimised. This letter seeks to provide you with certainty that the council has responded to your request to inspect such properties and to take action to prevent any further exposure to mould by any tenant. Where reference is made to the contents of the report titled ‘SFH statement of

, Consultant in Respiratory Medicine’, it should be made clear that the council does not have the direct knowledge to verify such references. In response to this request, please find below additional information along with supporting appendices.

Civic Centre, Chesterfield Road South, Mansfield, NG19 7BH T 01623 463463 E mdc@mansfield.gov.uk MyMansfieldUK @MDC_News

1. Background and timeline of events, including Mrs Bennett’s reports of mould and update on Regulation 28 request to inspect homes. A timeline of events is attached to this letter at Appendix 1. This includes details relating to Mrs Bennett’s tenancy, any repairs service requests and subsequent remedial action. A series of photos linked to this timeline of events are also attached and are labelled as Appendix 1 photos 1a-1b, Appendix 1 photos 1c-1m and Appendix 5 photos 5a-5q. Summarising the timeline of events at Appendix 1, the council responded to, investigated and successfully completed, all repairs requests, including those relating to dampness and mould, in full accordance with the target timescales as operated for the Repairs Service and set out within the council’s Repairs Policy. The council responded to Mrs Bennett’s requests relating to mould specifically and inspected giving consideration to known health conditions and vulnerabilities (which included COPD). The council took proactive action to identify any wider sources of any dampness and took proactive action to treat any mould. Mould growth was isolated to inside the tenant’s set of bedroom drawers and wardrobe on inspection. Mould growth was not identified in other locations within Mrs Bennett’s home. However, a zero tolerance approach was taken to mould and proactive mould treatment was undertaken as a preventative measure in the home to minimise any risk to Mrs Bennett’s health and wellbeing. Mrs Bennett was also provided with advice and guidance throughout her tenancy to support her to manage moisture levels. Mrs Bennett had not made any complaints to the council under the council’s complaints policy throughout the tenancy period. The Coroner’s Regulation 28 document received by the council included the following appendices:  Appendix 2 includes photographs taken by Mrs Bennett on 3rd and 4th January 2023 received from the Coroner along with the above Regulation 28 document on 24th November 2023.  Appendix 3 includes SFH Statement of Consultant in Respiratory Medicine received from the Coroner on 24th November 2023 along with the Regulation 28 document. In response to the request for the council to inspect properties in that area for mould, the council wrote to tenants accordingly. Appendix 4 details the letter dated 14 December 2023 sent by first class post by the council to council tenants living on Eather Avenue, Slant Lane and certain homes on Park Road advising that the

council wished to inspect their homes for mould. A total of 64 tenants received this letter along with accompanying advisory information. These addresses were contacted as they are the same building archetype in the immediate area of 23 Eather Avenue. Prior to this letter being sent, the council had 1 ongoing dampness request in that area which was actively being remedied. Following receipt of the letter, the council received contact from 13 tenants and inspections of each home have been organised in agreement with the tenant. To date, 41 homes have been inspected in total, mostly after the Christmas period, by a dedicated inspector. Of the homes inspected, mould growth has been identified in 15 homes and in all cases, mould growth has been minimal. In all cases where mould has been identified however, mould treatment will be completed in agreement with the tenant within the council’s repairs target timescales. Mould treatment works have started on site by a specialist mould treatment company. All 64 tenants have received detailed advice to support them to minimise moisture levels and reduce the risk of mould in the future. A second reminder letter will be sent week beginning 22 January 23 to those tenants that have not yet contacted the council with the aim of completing all remaining inspections by 16 February 23. This programme is dependent upon tenants allowing access. Whilst inspecting their homes, the council has also proactively noted any other repairs required, regardless of whether or not they relate to any dampness or mould growth.
2. Action taken to understand and act on the specific needs and vulnerabilities of Mrs Bennett in order to minimise the risks from mould exposure. In summary, the council gathered information from Mrs Bennett at the outset and throughout her tenancy and responded to all repairs requests, including those relating to dampness and mould, in full accordance with the target timescales as operated for the Repairs Service and set out within the council’s Repairs Policy. The council responded to Mrs Bennett’s requests relating to mould specifically and inspected giving consideration to known health conditions and vulnerabilities. The council took proactive action to identify any wider sources of any dampness and took proactive action to treat any mould. Mould growth was isolated to inside the tenant’s set of bedroom drawers and wardrobe on inspection. Mould growth was not identified in other locations within Mrs Bennett’s home. However, a zero tolerance approach was taken to mould and proactive mould treatment was undertaken in the home to minimise any risk to Mrs Bennett’s health

and wellbeing. Mrs Bennett was also provided with advice and guidance throughout her tenancy to support her to manage moisture levels. With reference to the Sherwood Forest Hospital (SFH) statement of Dr Hutchinson, 5th Consultant in Respiratory Medicine (Appendix 3), on June 2023 a consultant advises they were shown photos of mould on the walls of Mrs Bennett’s home. These photos have not been included within the SFH report and therefore the council are unable to comment on this. However, the photos provided by Mrs Bennett dated the 3rd and 4th of January 2023 (Appendix 2) that have been provided to the council by the Coroner appear to show mould on Mrs Bennett’s drawers and wardrobe only and not on any walls. At no point were the council advised of Mrs Bennett’s respiratory-related health conditions by the NHS (Sherwood Forest Hospital Trust or her GP) during the period of hospital admissions from March 2023 to June 2023. It should be noted however that all proactive repairs and mould treatment was completed well in advance of this date on 11th January 2023. The report concludes the cause of Mrs Bennett’s Interstitial Lund Disease (ILD) remains unclear. Blood tests which might support exposure to fungus were negative. Causes of ILD remained unclear and inconclusive. Possible causes included vaping, the medications Mrs Bennett was taking as well as possible mould (based on the photos the consultants were shown by Mrs Bennett). The report does not distinguish between these three factors. advises he did not see the mould himself and therefore it is difficult for him to give an opinion on the balance of probabilities whether it did in fact contribute. The council’s Customer Services team receive repairs requests on behalf of Housing Repairs and also have the ability to book inspections whilst on the telephone with tenants. When taking enquiries the service will triage and identify whether a tenant has any additional needs and vulnerabilities. In addition, any information provided as part of the allocations and sign-up process will be collected. In the case of Mrs Bennett, the council’s housing management/allocations team had recorded a number of matters relating to her health and wellbeing at the tenancy outset including difficulty in walking, anxiety, depression, fibromyalgia and mental health. Respiratory related health conditions were not declared by Mrs Bennett at this stage. Customer Services later noted that the health condition Chronic Obstructive Pulmonary Disease (COPD) was self-declared by Mrs Bennett on a repairs request raised on 26 October 2022 regarding a leaking roof affecting the bedroom ceiling. An inspection was subsequently arranged at the time of the report for 3 November 2022. The inspection of Mrs Bennett’s home took place as arranged as soon as possible on the 3 November 2022, 6 working days/8 calendar days from her initial request. Photos of Mrs Bennett’s home during this inspection are detailed in Appendix 1a-b.

As a result of this inspection, the source of the reported penetrating dampness in the bedroom was identified and an order for an external roofing contractor was raised on 15 November 2022. The roofing works were completed on 20 January 2023. The inspector also provided advice and guidance on minimising condensation build up within the bathroom and home generally. In the meantime, other repairs requested were also responded to in a timely manner as detailed in the timeline at Appendix 1. With regard to dampness and mould specifically, a later inspection took place on 5 January 2023, 15 calendar days (including Christmas and New Year Bank Holidays) after Mrs Bennett self-reported damp in her kitchen. Photos of Mrs Bennett’s home during this inspection are detailed in Appendix 1c-1m. An inspection took place of the entire home and, on inspection, mould growth was evident inside the tenant’s wardrobe and chest of drawers in the bedroom (as seen in the photos in Appendix 1c-1m). Mould was not identified on the bedroom walls however or in the kitchen as reported. It was also noted that the bed and bed head was situated directly in front of the radiator in the bedroom thus limiting the circulation of warm air in the room. Mrs Bennett was advised to move the bed away from the radiator where possible to maximise the circulation of warm air. Whilst in no way seeking to attribute ‘blame’ to the tenant, it was also noted that the tenant was using an unvented tumble dryer within the property (within the outhouse as detailed in photos in Appendix 1c-1m) and advice and guidance was therefore provided that this would significantly increase the amount of moisture entering her home and thus contributing to condensation. Further advice was provided to support Mrs Bennett around how to control moisture levels along with heating and ventilating the bungalow. In addition to this advice to the tenant, as a result of this inspection, the council also took further proactive action as a responsible landlord to minimize the further risk of mould by replacing existing extractor workings, installation of additional passifying vents in the bedroom and lounge and immediate arrangements were made to wash down and treat the bedroom wall as a preventative and proactive measure. Mould treatment was subsequently completed on 11 January 2023, 6 calendar days/4 working days after the inspection.
3. Information on the condition of the property and its compliance with the Decent Homes Standard. The council commissioned Savills to complete a 30% physical stock condition survey late 2021 with inspections taking place late 2021 to the Spring of 2022. 23 Eather Avenue was included within the Savills survey schedule and was inspected on 6 December 2021. The property was deemed decent and no category 1 hazards were

identified as a result of the decency assessment/survey. The survey notes did not indicate the presence of mould or a lack of other key features such as electrical ventilation. The stock condition survey included 11 other homes on Eather Avenue and 3 homes on Slant Lane of this archetype, each of which was assessed as decent and without any identified category 1 hazards at the time of the survey. Prior to Mrs Bennett’s tenancy start date, the property underwent various works during the void period including:  Internal repairs and cleaning  Electrical safety check  Gas safety commissioning  Smoke detector check  Garden/external works The property met the decent homes standard at the point at which the property was re-let to Mrs Bennett and achieved a Band C Energy Performance Certificate (EPC) rating. Photos of the property at the end of Mrs Bennett’s tenancy after her tragic death are included at Appendix 5 (photos 5a to 5q) and show no mould growth.
4. How risks of mould exposure to other council tenants are being minimised. In terms of responding to the Coroner’s Regulation 28 document relating to the area of homes near Eather Avenue, the council wrote to 64 homes dated 14 December 2023 as detailed in section 1. A dedicated inspector has completed home inspections along with the provision of tailored advice to tenants. Whilst at the tenant’s home, the inspector has proactively identified any wider sources of dampness, if present, along with any other non-damp/mould related repairs. In terms of the wider housing stock, further details regarding the council’s approach to minimising the risk of mould exposure to other tenants is detailed in section 5b below.
5. The council’s overall approach to: a) decent homes compliance; The council owns retained housing stock of 6326 homes, including 10 sheltered housing schemes. Our approach to safety and decency is a priority focus. In terms of stock quality and our understanding of this, the council commissioned Savills to undertake a 30% stock condition survey during 2021 with inspections taking place late 2021 to the Spring of 2022.

This data has helped shape the direction and investment profile of our homes over the short, medium and longer term. This work combined has resulted in a significant increase in sustainable capital investment in council homes as part of the medium term financial strategy. Increased financial resource and capacity in this area also contributes to the council’s approach to addressing the root causes of damp and mould via windows, doors, roofing, heating and electrical upgrade programmes. As well as responsive day to day repairs, the Housing service delivers major capital improvement work to its homes including roofing, windows, doors, electrical upgrades, heating upgrades, sheltered scheme refurbishment, fire safety work etc. The total capital budget for 24/25 totals circa £17,000,000 to facilitate the renewal of key building components following a stock condition survey with significant investment continuing in future years. The council has also taken part in the social housing decarbonisation demonstrator project as well as a domestic retrofit project within the D2N2 devolution programme with a view to improving the thermal efficiency of council homes. The void (empty) period is also used as an opportunity to bring homes up to the decent homes standard in its entirety where, for example, tenants have refused access previously. b) tackling damp and mould. We have adopted a triangulated approach to assessing and appraising the extent of damp, condensation and mould growth in council homes including:  Independent stock condition surveys as mentioned in 5a above.  Early, proactive action. Inspectors identify the root cause of damp and mould at the earliest opportunity with the support of a range of trained operatives attending to treat any mould with escalation to qualified professionals as required. All operatives have received both Housing Health and Safety Rating (HHSRS) training appropriate to their roles as well as damp and mould training. Training to utilise dampness measurement equipment has also been completed.  Colleague and Stakeholder awareness - Expanded knowledge and awareness of other colleagues and contractors to ‘don’t walk by’, reporting any instances of damp, condensation and mould growth. This triangulated model enables us to regularly understand and evaluate property condition to revise our approach to planned investment and cyclical maintenance, and to monitor delivery performance.

Our approach to remedying issues concerning damp, condensation and mould growth focusses on;  Upon tenant contacting us, we schedule either a trained Operative or external specialist Contractor to attend to treat and remove any reported instances of mould growth, and prevent the worsening of condition.  Within this visit we triage the root cause of damp, undertaking any proactive repairs, scheduling follow-on works or arranging technical inspections by specialist Inspectors or Building Surveyors as required. Other proactive actions include;  Cross-teams training to improve awareness of the risks of damp and mould growth and to ensure stakeholders can alert the team to instances of, and resolve any damp and mould growth cases.  We co-produced guidance information and support for tenants to help identify instances of damp, mould and condensation and help to reduce high levels of internal moisture in properties.  Ongoing damp and mould social media campaign that has been running on council social media accounts since November 2023. In total the campaign has reached 85,778 people on Facebook and a further 3,815 on X (formerly Twitter).  Guidance information has also taken the form of physical leaflets that are provided in tenancy start-up packs and during property inspections by the repairs team as well as Housing Officers and Community Safety officers.  The Summer 2023 Housing Contact magazine delivered to a tenants featured detailed advice on damp, condensation and mould growth and how to seek help as well as other means of support.  The council’s Housing web pages feature a range of advice and guidance on damp, mould and condensation with links to other useful sources of information around welfare benefits, affordable warmth, food clubs, priority registers and the council’s ASSIST support team.  Proactive working and established links with health, public health and social care (including safeguarding teams) and education providers to support identification and resolution of damp, condensation and mould growth factors found in tenant’s homes, and encouraging instances to be reported for prompt action. The undertook a ‘Preventing Family Homeless’ pilot with Children’s

social care to raise awareness between Housing and Care teams around housing-related issues including property condition and created fast-track referral pathways for issues such as damp and mould.  The council is currently developing a pilot project in Mansfield with Mid-Notts Place Based Partnership and health partners to train social prescribers in housing matters, including damp and mould growth, with specific emphasis on families with children experiencing respiratory conditions.  Provision of a Mansfield ‘Healthy Homes Hub’ (See Appendix 6) to support the most vulnerable tenants and residents to stay safe in their home. Support with property condition, including damp, mould and condensation, is included within the hub model.  Provision of an ASSIST Hospital Discharge service in partnership with Sherwood Forest Hospital Trust and the Integrated Care System (See Appendix 7) to support discharge cases requiring housing-related support (which can include property conditions such as damp, mould and condensation matters) and prevent admission through work in the community.  Working with external contractors to ensure early warning ‘on the ground’ of damp and mould growth in properties enabling us to proactively respond and prevent any further property damage and tenant risk.  The council have commissioned an independent consultant from Savills to review the council’s approach to damp and mould.  Introduced an interim procedure that considers the potential timescales and actions suggested in the consultation document - Awaab’s Law: Consultation on timescales for repairs in the social rented sector.  Introduced a triage system with scripted prompts for all reported damp, mould and condensation cases reported by the tenant.  Updated our website to provide further guidance on damp, mould and condensation including tips to reduce moisture in the home.  Ongoing frequent performance management meetings with contractors dealing with damp and mould treatment to monitor progress and ensure properties are prioritised where there are occupants that could be significantly affected by damp and mould due to medical conditions.

 Trialling environmental monitoring devices for placement in tenant’s homes to assist with supporting tenants that report damp, mould or condensation.  Increased the capacity of the inspection team responsible for visiting homes and investigating reports of damp, mould and condensation.  Increase the capacity of contractors, both local and framework contractors, to support with damp works and mould treatments to ensure a prioritised and timely response to damp and mould treatment.  Procured mould kits from specialist mould treatment company for tenant usage to support tenants to prevent mould growth where appropriate.  Planned councillor workshop focussing on damp, mould and condensation to assist members to provide advice and signposting to constituents. I trust this satisfies your request and assures the Coroner that the council does indeed take its role as landlord and tenant health and wellbeing very seriously. However if you require any further information please do not hesitate to contact us and we will of course assist as soon as possible.