Afolabi Ojerinde: Prevention of Future Deaths Report

Suicide (from 2015)

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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
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
1CORONER

I am Zak GOLOMBECK, HM Area Coroner for the coroner area of Manchester City
2CORONER’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.
3INVESTIGATION 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.
4CIRCUMSTANCES 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.
5CORONER’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.
6ACTION 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.
7YOUR 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.
8COPIES 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.
9Dated: 03/02/2025
Zak GOLOMBECK
HM Area Coroner for Manchester City