Jane Bennett: Prevention of future deaths report

Other related deaths

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Date of report: 24/11/2023

Ref: 2023-0495

Deceased name: Jane Bennett

Coroner name: Neema Sharma

Coroner Area: Nottingham City and Nottinghamshire

Category: Other related deaths

This report is being sent to: Mansfield District Council

[REDACTED] Head of Housing, Mansfield District Council
I am Miss Neena Sharma, HM Coroner, for the coroner area of Nottingham City and Nottinghamshire
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 23rd August 2023, I commenced an investigation into the death of Jane BENNETT, aged 52. Mrs. Bennett died on 8th June 2023 at Kings Mill Hospital, Mansfield Road, Sutton-in- Ashfield, Nottinghamshire, NG17 4JL.  

A post mortem examination was undertaken by [REDACTED] , at the instruction of HMC for Nottinghamshire. In a report dated 8th August 2023, she gave the cause of death as 1a Acute exacerbation of non-specific interstitial pneumonitis.  

In her comments to the Coroner she said: “In the view of history and autopsy findings in my opinion death was due to acute infective exacerbation of interstitial lung disease. Mould in her house could have contributed for the development of interstitial lung disease.”
Mrs. Bennett lived in a house provided by Mansfield District Council from October 2022 until her final admission to hospital in late May 23. She identified severe mould in her property. Photographs are attached.  

Mrs Bennett had a diagnosis of interstitial pneumonitis made on CT scan 01/04/23 and she then had frequent admissions to hospital with worsening respiratory function in April and May 2023.  

Mrs Bennett was admitted to ITU for the second time on 28/05/23 with type 1 respiratory failure requiring high flow nasal oxygen/NIV, high dose IV steroids, antifungals and antibiotics throughout her admission. She failed to respond to medical management , and sadly died on 8.6.23.  

The cause of her interstitial pneumonitis is not clear at this stage, but both the Pathologist and the Respiratory Consultant, [REDACTED] in his report to the Coroner dated 26.9.23 (report attached) are clear that the mould may be causal or contributory to her death. This will be further explored at a forthcoming Inquest, date to be finalised.
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:
I am concerned 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. I ask 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.
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 19th January 2024. 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: –
Family of Jane Bennett
Mansfield District Council 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.
924th November 2024
HM Coroner
Nottingham City and Nottinghamshire