Afolabi Ojerinde: Prevention of Future Deaths Report
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Date of report: 03/02/2025
Ref: 2025-0060
Deceased name: Afolabi Ojerinde
Coroners name: Zak Golombeck
Coroners Area: Manchester City
Category: Suicide (from 2015)
This report is being sent to: Department for Work and Pensions | Energy Institute | Association for Petroleum and Explosives Administration | The Petroleum Enforcement Liaison Group
REGULATION 28 REPORT TO PREVENT DEATHS | |
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THIS REPORT IS BEING SENT TO: 1 Secretary of State for Work and Pensions 2 Energy Institute 3 Association for Petroleum and Explosives Administration 4 The Petroleum Enforcement Liaison Group | |
1 | CORONER I am Zak GOLOMBECK, HM Area Coroner for the coroner area of Manchester City |
2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
3 | INVESTIGATION and INQUEST On 05 September 2023 I commenced an investigation into the death of Afolabi Oluwafemi OJERINDE aged 48. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was that: The deceased, who suffered from a psychotic illness, attended an [REDACTED] petrol station on 4th September 2023 where he was able to pay for and dispense petrol into a plastic water bottle. He then ignited the petrol and placed himself in the fire. The deceased died on 5th September 2023 at Wythenshawe Hospital from the effect of injuries sustained during the incident on 4th September 2023. The deceased died on 5th September 2023 at Wythenshawe Hospital from the effect of injuries sustained during the incident on 4th September 2023. |
4 | CIRCUMSTANCES OF THE DEATH The Deceased attended an [REDACTED] petrol station. After paying at the pump with a credit/debit card, was able to dispense petrol into a plastic bottle (not a suitable portable container) [REDACTED] . It was confirmed in evidence that the petrol station is not continuously watched, and that for a person attending without a vehicle, an alarm would only be raised after [REDACTED] minutes. Such control measures did not, therefore, have any bearing on the Deceased being able to dispense petrol in contravention of Regulation 12 of the Petroleum (Consolidation) Regulations 2014. The Deceased proceeded to ignite the petrol and place himself in the fire. He subsequently died of his injuries. |
5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) I am concerned about the safety of [REDACTED] petrol stations and how they do not ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014. When comparing this to [REDACTED] petrol stations, [REDACTED] ensuring that the individual is: seeking to dispense petrol into a motor vehicle or motor boat; seeking to dispense petrol into a suitable portable container; over the age of 16. The evidence at the Inquest from the companies that operated the site and provided security accepted that the guidance available for [REDACTED] petrol stations do not and cannot ensure compliance with the 2014 Regulations. |
6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by March 31, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] Tesco Stores LTD Chubb Fire & Security UK LTD Pennine Care NHS Foundation Trust I have also sent it to Greater Manchester Fire and Rescue Service who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
9 | Dated: 03/02/2025 Zak GOLOMBECK HM Area Coroner for Manchester City |