Zainab Hashim and Tafaoul Abdulkarim
PFD Report
All Responded
Ref: 2021-0205
Child Death (from 2015)
Community health care and emergency services related deaths
Other related deaths
All 1 response received
· Deadline: 1 Oct 2021
Coroner's Concerns (AI summary)
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.
View full coroner's concerns
During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help.
It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy.
During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties.
Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring.
It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy.
During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties.
Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring.
Responses
Action Planned
The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are piloting the provision of portable induction loops to assist tenants with hearing impairments. (AI summary)
The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are piloting the provision of portable induction loops to assist tenants with hearing impairments. (AI summary)
View full response
Dear Ms Serrano Regulation 28 Report - Zainab Adam Bargo Hashim and Tafaoul Abdulillia Abdulkarim In response to your Regulation 28 Report to Prevent Future Deaths dated 16 June 2021 following the inquest into the deaths of Zainab Adam Bargo Hashim and Tafaoul Abdulillia Abdulkarim this letter sets out how Stoke-on-Trent City Council communicates its Stay Put Policy to residents who live in council owned blocks where a Stay Put Policy applies (“Stay Put Blocks”) post October 2017, the frequency of that communication and planned future actions. How the Stay Put Policy is communicated All residents in Stay Put Blocks receive a copy of the Fire Safety Notice (Appendix A) produced in partnership with Staffordshire Fire and Rescue Service which sets out concisely what they should do in the event of a fire. The Fire Safety Notice is translated and provided to tenants in their first language. Such information is obtained from tenants when they sign up to the Council’s Housing Waiting List. The Council routinely translates the Fire Safety Notice into the 14 languages that are commonly spoken within the city (Czech, Polish, Russian, Bengali, Urdu, Arabic, Farsi, Kurdish, Mandarin, Pashto, Punjabi Pakistan, Punjabi Indian, Slovak and Turkish) and any others as may be required (Appendix B). The Fire Safety Notice which communicates the Stay Put Policy in English is displayed prominently in communal areas on every floor of every Stay Put Block within the city. It also communicates the circumstances in which ‘Stay Put’ should be abandoned i.e. if smoke or heat affects a resident’s home or if they are instructed to leave by the fire and rescue service. The Stay Put Policy is verbally communicated to tenants of the Stay Put Blocks when an annual Tenancy Audit Visit is carried out by Housing Officers. Housing Officers are trained on Fire Safety Awareness and how to communicate the Stay Put Policy. This training is refreshed annually. City Director’s Office Civic Centre Glebe Street Stoke-on-Trent ST4 1HH
Page 2 The Council has updated its Fire Safety Scripting Note, which is used by Housing Officers to deliver the Stay Put Policy during the Tenancy Audit Visit, to ensure consistency. It now requires Housing Officers to hand out the Fire Safety Notice and ask tenants the following questions:
i. Do you know there is a Stay put policy;
ii. Do you understand the Stay Put Policy; and
iii. Do you know that as a tenant you are responsible for advising other members of their household / visitors about the Stay Put Policy? The Tenancy Audit form requires tenants to sign to confirm they are aware that there is a Stay Put Policy. Housing Officers do not sign off a Tenancy Audit Visit and leave a tenant’s flat until they are satisfied that a tenant has fully understood the Stay Put Policy. Tenants are asked to sign a written declaration at the start of their tenancy, at the 6 week New Tenancy Visit and all subsequent Tenancy Audits to record they have received the following information:
- fire safety information (including the Stay Put Policy) has been provided and fully explained to them;
- the language the fire safety information was provided,
- that they have understood the fire safety information and
- they will provide this information to all members of their household to ensure that they also understand the importance of fire safety. Where English is not a tenant’s first language, the Lettings staff will employ the services of a translator to attend Sign Up Visits with them to translate the Stay Put Policy (amongst other things) and to interpret any questions asked. This service is free of charge to tenants. This process is recorded in a recently developed Fire Safety Advice Check List. If a tenant requires ongoing translation support at Tenancy Audit Visits this is provided by arranging for the attendance of family and friends who speak English or if necessary the services of a professional translator will again be provided by the Council. To ensure the Stay Put Policy is communicated effectively to residents of Stay Put Blocks who may have a learning style not suited to text information, the Fire Safety Notice also contains illustrative imagery next to key points. This also helps to reinforce understanding. Housing Officers ensure that they communicate to tenants with disabilities in a manner which is best suited to their needs, using written or verbal communication and also the support of family and friends or other Council department / other agencies as appropriate. For tenants with disabilities who are likely to require additional support to evacuate in the event of a fire the Council requests that Staffordshire Fire and Rescue Service carries out a fire safety visit to their flat to reinforce the Stay Put Policy and to discuss how they would evacuate if required to do so by the fire and rescue service. This is in addition to the person-centred risk assessments carried out by the Council on all tenants as part of Tenancy Audits. For tenants who are hard to engage the Council’s Housing Officers work closely with other Council Departments (e.g. Adult Social Care), trusted stakeholders including Staffordshire Fire and Rescue
Page 3 Service, Staffordshire Police, Mental Health Support Workers and General Practitioners to arrange joint visits. As a recent example of this, Housing Officers conducted a joint visit with Staffordshire Fire and Rescue Service and Staffordshire Police to provide reassurance around the Stay Put Policy. In addition to the above, Proactive Calls to tenants have been introduced whereby the Council will attempt to contact all tenants by telephone and discuss fire safety and to check understanding about the Stay Put Policy where appropriate amongst other matters. This method of communication is also used to update our records of any changes in the tenant’s details, and listen to tenant’s views on how safe and secure they feel. The Council has a Tenant Board which represents the diverse demographic residing in Council owned and managed social housing in Stoke-on-Trent, with the purpose of giving tenants a voice on key aspects of housing management. The seven Tenant Board Members are involved in how the Stay Put Policy is communicated and recently participated in trialling the Proactive Calls. A copy of the Fire Safety Notice is sent to all leaseholders and the Stay Put Policy is also a standing item in the Leaseholder Newsletter. The Council holds community events which include fire safety (which Staffordshire Fire and Rescue Service attend), to which residents are invited. These community events are held at various locations across the City and are widely publicised to ensure maximum uptake. The Council has facilitated Staffordshire Fire and Rescue Service attending the surgeries of local councillors in Stoke-on-Trent to reinforce the importance of Stay Put. The Council also promotes the following services provided by Staffordshire Fire and Rescue Service to its residents:
- to attend Resident Association meetings,
- Community Advice Team which now offers a free home fire safety checks via a free phone telephone number (0800 0241 999 lines are open from 8am-5pm, Monday to Friday). Following the publication of the Government’s White Paper on social housing: The charter for social housing residents in November 2020 which was developed following the tragic fire at Grenfell Tower, the Council has developed a Customer Engagement Strategy which aims to deliver the expectations contained within that charter with particular emphasis on ensuring tenants have a voice and are heard. Frequency of how the Stay Put Policy is communicated The Fire Safety Notice is provided to all new tenants when they sign-up for their tenancy along with a copy of a Home Office produced Fire Safety Poster (Appendix C), the Fire Safety Scripting Note and the Fire Safety Check List. To ensure the Stay Put Policy is regularly communicated Fire Safety Letters and Fire Safety Notices are given by hand to all new tenants at tenancy sign up. A further copy of the Fire Safety Notice is handed to tenants at the 6 weeks new tenancy visits, again at 6 months and then going forward to all tenants every 12 months, as part of annual Tenancy Audit Visits. If at any time Housing Officers struggle to gain access to a flat the Fire Safety Notice will be put through the letter box (translated into their first language) or it will be emailed to the tenant if that is their preferred method of communication.
Page 4 The Council continually adapts and improves how it communicates with its residents and when COVID 19 restrictions have prevented home visits, telephone calls have been made to tenants to discuss fire safety and fire safety notices have been posted through letter boxes. A copy of the Fire Safety Notice is sent to leaseholders at the time they purchase the property from the Council through Right to Buy scheme and when the leaseholder sells their interest on the open market. Leaseholders also receive the Leaseholder Newsletter annually. Action to be Taken The Chair and Vice Chair of the Tenant Board will accompany Council Housing Officers when they conduct Fire Safety Audits of Stay Put Blocks. They have received Fire Safety Awareness Training in preparation for this role. The Council will continue to be guided by the information and best practice shared at its Fire Safety Group Meetings at which Staffordshire Fire and Rescue Service attend. We have just consulted on our Customer Engagement Strategy and will consider all feedback. Housing Officers undertaking Tenancy Audit Visits will be required to undertake enhanced training on communicating with tenants who don’t speak English as a first language. We are also in the formative stages of developing a video on fire safety and Stay Put and a series of questions and answers to help to communicate the Stay Put Policy to residents with different types of learning styles. It is intended that the video will be watched during the application process for Council housing by those who have been offered a Council property and be available to all tenants. Fire Safety Notices will be posted through the letterbox of all leaseholder properties and leaseholders will be made aware that it is their responsibility as landlord to make sure that their sub tenants are aware of the Stay Put Policy and understand it. This will start with immediate effect. The Council will review the frequency of how it communicates with leaseholders around fire safety and Stay Put. The Council has a provisional plan in place for leaseholders to be sent fire safety information with council bills, by way of an additional reminder. The Council will consider increasing the use of targeted digital communication methods to convey the message of Stay Put to residents in Stay Put Blocks e.g. including this information in mast banners, signature boxes, tenants e bulletins and rent bills. The Council is also exploring the effectiveness of also displaying an additional notice in communal areas of all Stay Put Blocks explaining that the Fire Safety Notice can be requested in other languages. More in depth questioning will be undertaken of tenants in Stay Put Blocks, of their understanding of the Stay Put Policy. Feedback obtained will be used to inform the Council’s communication strategy around fire safety going forward. Conclusion We thank you for the concerns that you have raised. Stoke-on-Trent City Council places a very high level of importance on fire safety, as demonstrated by our commitment to communicating the Stay Put Policy to our residents effectively and our investment in other fire safety measures such as sprinkler systems. We also await the coming into force of new legislation and the publication of further national guidance later this year in relation to fire safety in blocks of flats as a result of the
Page 5 Grenfell Tower Inquiry and the Government consultation on Personal Emergency Evacuation Plans in High Rise Residential Buildings and will be monitoring these changes, seeking professional support to implement them and ensure that staff receive formal training on the new legislation and guidance.
Page 2 The Council has updated its Fire Safety Scripting Note, which is used by Housing Officers to deliver the Stay Put Policy during the Tenancy Audit Visit, to ensure consistency. It now requires Housing Officers to hand out the Fire Safety Notice and ask tenants the following questions:
i. Do you know there is a Stay put policy;
ii. Do you understand the Stay Put Policy; and
iii. Do you know that as a tenant you are responsible for advising other members of their household / visitors about the Stay Put Policy? The Tenancy Audit form requires tenants to sign to confirm they are aware that there is a Stay Put Policy. Housing Officers do not sign off a Tenancy Audit Visit and leave a tenant’s flat until they are satisfied that a tenant has fully understood the Stay Put Policy. Tenants are asked to sign a written declaration at the start of their tenancy, at the 6 week New Tenancy Visit and all subsequent Tenancy Audits to record they have received the following information:
- fire safety information (including the Stay Put Policy) has been provided and fully explained to them;
- the language the fire safety information was provided,
- that they have understood the fire safety information and
- they will provide this information to all members of their household to ensure that they also understand the importance of fire safety. Where English is not a tenant’s first language, the Lettings staff will employ the services of a translator to attend Sign Up Visits with them to translate the Stay Put Policy (amongst other things) and to interpret any questions asked. This service is free of charge to tenants. This process is recorded in a recently developed Fire Safety Advice Check List. If a tenant requires ongoing translation support at Tenancy Audit Visits this is provided by arranging for the attendance of family and friends who speak English or if necessary the services of a professional translator will again be provided by the Council. To ensure the Stay Put Policy is communicated effectively to residents of Stay Put Blocks who may have a learning style not suited to text information, the Fire Safety Notice also contains illustrative imagery next to key points. This also helps to reinforce understanding. Housing Officers ensure that they communicate to tenants with disabilities in a manner which is best suited to their needs, using written or verbal communication and also the support of family and friends or other Council department / other agencies as appropriate. For tenants with disabilities who are likely to require additional support to evacuate in the event of a fire the Council requests that Staffordshire Fire and Rescue Service carries out a fire safety visit to their flat to reinforce the Stay Put Policy and to discuss how they would evacuate if required to do so by the fire and rescue service. This is in addition to the person-centred risk assessments carried out by the Council on all tenants as part of Tenancy Audits. For tenants who are hard to engage the Council’s Housing Officers work closely with other Council Departments (e.g. Adult Social Care), trusted stakeholders including Staffordshire Fire and Rescue
Page 3 Service, Staffordshire Police, Mental Health Support Workers and General Practitioners to arrange joint visits. As a recent example of this, Housing Officers conducted a joint visit with Staffordshire Fire and Rescue Service and Staffordshire Police to provide reassurance around the Stay Put Policy. In addition to the above, Proactive Calls to tenants have been introduced whereby the Council will attempt to contact all tenants by telephone and discuss fire safety and to check understanding about the Stay Put Policy where appropriate amongst other matters. This method of communication is also used to update our records of any changes in the tenant’s details, and listen to tenant’s views on how safe and secure they feel. The Council has a Tenant Board which represents the diverse demographic residing in Council owned and managed social housing in Stoke-on-Trent, with the purpose of giving tenants a voice on key aspects of housing management. The seven Tenant Board Members are involved in how the Stay Put Policy is communicated and recently participated in trialling the Proactive Calls. A copy of the Fire Safety Notice is sent to all leaseholders and the Stay Put Policy is also a standing item in the Leaseholder Newsletter. The Council holds community events which include fire safety (which Staffordshire Fire and Rescue Service attend), to which residents are invited. These community events are held at various locations across the City and are widely publicised to ensure maximum uptake. The Council has facilitated Staffordshire Fire and Rescue Service attending the surgeries of local councillors in Stoke-on-Trent to reinforce the importance of Stay Put. The Council also promotes the following services provided by Staffordshire Fire and Rescue Service to its residents:
- to attend Resident Association meetings,
- Community Advice Team which now offers a free home fire safety checks via a free phone telephone number (0800 0241 999 lines are open from 8am-5pm, Monday to Friday). Following the publication of the Government’s White Paper on social housing: The charter for social housing residents in November 2020 which was developed following the tragic fire at Grenfell Tower, the Council has developed a Customer Engagement Strategy which aims to deliver the expectations contained within that charter with particular emphasis on ensuring tenants have a voice and are heard. Frequency of how the Stay Put Policy is communicated The Fire Safety Notice is provided to all new tenants when they sign-up for their tenancy along with a copy of a Home Office produced Fire Safety Poster (Appendix C), the Fire Safety Scripting Note and the Fire Safety Check List. To ensure the Stay Put Policy is regularly communicated Fire Safety Letters and Fire Safety Notices are given by hand to all new tenants at tenancy sign up. A further copy of the Fire Safety Notice is handed to tenants at the 6 weeks new tenancy visits, again at 6 months and then going forward to all tenants every 12 months, as part of annual Tenancy Audit Visits. If at any time Housing Officers struggle to gain access to a flat the Fire Safety Notice will be put through the letter box (translated into their first language) or it will be emailed to the tenant if that is their preferred method of communication.
Page 4 The Council continually adapts and improves how it communicates with its residents and when COVID 19 restrictions have prevented home visits, telephone calls have been made to tenants to discuss fire safety and fire safety notices have been posted through letter boxes. A copy of the Fire Safety Notice is sent to leaseholders at the time they purchase the property from the Council through Right to Buy scheme and when the leaseholder sells their interest on the open market. Leaseholders also receive the Leaseholder Newsletter annually. Action to be Taken The Chair and Vice Chair of the Tenant Board will accompany Council Housing Officers when they conduct Fire Safety Audits of Stay Put Blocks. They have received Fire Safety Awareness Training in preparation for this role. The Council will continue to be guided by the information and best practice shared at its Fire Safety Group Meetings at which Staffordshire Fire and Rescue Service attend. We have just consulted on our Customer Engagement Strategy and will consider all feedback. Housing Officers undertaking Tenancy Audit Visits will be required to undertake enhanced training on communicating with tenants who don’t speak English as a first language. We are also in the formative stages of developing a video on fire safety and Stay Put and a series of questions and answers to help to communicate the Stay Put Policy to residents with different types of learning styles. It is intended that the video will be watched during the application process for Council housing by those who have been offered a Council property and be available to all tenants. Fire Safety Notices will be posted through the letterbox of all leaseholder properties and leaseholders will be made aware that it is their responsibility as landlord to make sure that their sub tenants are aware of the Stay Put Policy and understand it. This will start with immediate effect. The Council will review the frequency of how it communicates with leaseholders around fire safety and Stay Put. The Council has a provisional plan in place for leaseholders to be sent fire safety information with council bills, by way of an additional reminder. The Council will consider increasing the use of targeted digital communication methods to convey the message of Stay Put to residents in Stay Put Blocks e.g. including this information in mast banners, signature boxes, tenants e bulletins and rent bills. The Council is also exploring the effectiveness of also displaying an additional notice in communal areas of all Stay Put Blocks explaining that the Fire Safety Notice can be requested in other languages. More in depth questioning will be undertaken of tenants in Stay Put Blocks, of their understanding of the Stay Put Policy. Feedback obtained will be used to inform the Council’s communication strategy around fire safety going forward. Conclusion We thank you for the concerns that you have raised. Stoke-on-Trent City Council places a very high level of importance on fire safety, as demonstrated by our commitment to communicating the Stay Put Policy to our residents effectively and our investment in other fire safety measures such as sprinkler systems. We also await the coming into force of new legislation and the publication of further national guidance later this year in relation to fire safety in blocks of flats as a result of the
Page 5 Grenfell Tower Inquiry and the Government consultation on Personal Emergency Evacuation Plans in High Rise Residential Buildings and will be monitoring these changes, seeking professional support to implement them and ensure that staff receive formal training on the new legislation and guidance.
Sent To
- Stoke-on-Trent City Council
Response Status
Linked responses
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56-Day Deadline
1 Oct 2021
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 11/10/2017 I commenced an investigation into the death of Zainab Adam Bargo Hashim (“Zainab”), aged 36 and Tafaoul Abdulillia Abdulkarim (“Tafaoul”), aged 6. The investigation concluded at the end of the inquest on 11th June 2021.
The conclusion of the inquest was a narrative conclusion detailing that both Zainab and Tafaoul died from the effects of inhalation of smoke fumes, in the communal area of the block of flats, whilst attempting to flee a fire that had started in a separate flat.
The Medical Cause of death after Post Mortem is :
Zainab
1a) Hypoxic/ischaemic brain injury due to inhalation of fire fumes
Tafaoul
1b) Complications of inhalation of fire fumes (including hypoxic/ischaemic brain damage).
The conclusion of the inquest was a narrative conclusion detailing that both Zainab and Tafaoul died from the effects of inhalation of smoke fumes, in the communal area of the block of flats, whilst attempting to flee a fire that had started in a separate flat.
The Medical Cause of death after Post Mortem is :
Zainab
1a) Hypoxic/ischaemic brain injury due to inhalation of fire fumes
Tafaoul
1b) Complications of inhalation of fire fumes (including hypoxic/ischaemic brain damage).
Circumstances of the Death
Zainab Adam Bargo Hashim passed away at the Royal Stoke University Hospital, Stoke-on-Trent on the 2 October 2017 from ‘Hypoxic/ischaemic brain injury due to inhalation of fire fumes’. Tafaoul Abdulilla Abdulkarim passed away two days later on the, on the 4 October 2017 from ‘Complications of inhalation of fire fumes (including hypoxic/ischaemic brain damage)’.
On the 1 October 2017 Zainab left her home address home address of Ringland Close, because a fire had started in of the same block. To leave the block she had to go into the communal area of the block of flats which had become filled with smoke and fire fumes. The fumes caused Zainab, and her children, Tafoul, who was 6 years old, and , who was 6 months old, to collapse, and become unconscious. All were rescued by the Fire Service and taken to the Royal Stoke University Hospital where Zainab and Tafaoul passed away.
On the 1 October 2017 Zainab left her home address home address of Ringland Close, because a fire had started in of the same block. To leave the block she had to go into the communal area of the block of flats which had become filled with smoke and fire fumes. The fumes caused Zainab, and her children, Tafoul, who was 6 years old, and , who was 6 months old, to collapse, and become unconscious. All were rescued by the Fire Service and taken to the Royal Stoke University Hospital where Zainab and Tafaoul passed away.
Copies Sent To
4) Staffordshire Fire Service
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.