Brian Harfield: Prevention of future deaths report

Other related deaths

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Date of report: 16/03/2023

Ref: 2023-0092

Deceased name: Brian Harfield

Coroner name: Penelope Schofield

Coroner Area: West Sussex

Category: Other related deaths

This report is being sent to: Department for Levelling up, Housing and Communities

The Rt Hon Michael Gove Secretary of State for Levelling up, Housing and Communities 2 Marsham Street London SW1P 4DF
I am Penelope Schofield , Acting Senior Coroner, for the coroner area of West Sussex
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.
On 14th June 2022 I commenced an investigation into the death of Brian George Harfield aged 85. The investigation concluded at the end of the inquest on 3rd March 2023.
The overall conclusion of the inquest was a short form conclusion of Misadventure.
On 3rd May 2022 a fire started in the living room of Mr Harfield’s flat in the proximity of his recliner chair. It is unclear how the fire started but it was more likely than not caused by the wiring of a lamp which was located close by. Sadly Mr Harfield was overcome by the smoke and was found unconscious in his kitchen. Despite medical intervention by the Fire Brigade he sadly did not recover and was pronounced deceased at the scene.
During 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:  
The concerns relates to the fact that there is a lack of compulsory provision for sprinklers or other fire safety measures to protect those who live at home (outside of care homes) but are being provided with extra care facilities or those in retirement type provision.   Due to there being an ageing population and a lack of care home spaces there is a growing number of people (who would normally be residing in care homes) who are now having to buy care packages to be delivered either in their own homes or other residential type of facilitates. The providers of such accommodation are not subject to any fire safety provisions. People who find themselves in this type of facility do suffer declining health and mobility as time goes on. They are at a particular risk should a fire occur. They are more at risk than those in care homes as there is 24/7 staffing and trained individuals who are well versed in responding to a fire situation and evacuating the residents from the affected areas of the premises.
In an extra care facility it is highly probable that should a fire start that the occupant would be unable to leave the room of fire origin/ flat of origin through ill health/ poor mobility, and who would be overcome by the toxic products of combustion prior to the Fire and Rescue service being alerted. This is exactly what happened in Mr Harfield’s case.
We heard at this Inquest that whilst a sprinkler controlled fire would still produce smoke it would be of a lower level, and there is evidence that on the majority of occasions it does not just restrict the fires growth, but actually extinguishes it.
It is understood that there is currently a Government consultation being undertaken on the subject of Sprinklers in Care homes but the scope of this consultation does not cover the specific risk to those in extra care facilities. This is a missed opportunity.
The consultation can be found here. Sprinklers in care homes, removal of national classes, and staircases in residential buildings – GOV.UK (
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.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th June 2023 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:-
a)   The family of Brian Harfield
b)   West Sussex Fire Service
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 16/03/2023 Penelope SCHOFIELD Senior Coroner for West Sussex Coroners Service