William Erskine: Prevention of future deaths report
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Date of report: 17/04/2024
Ref: 2024-0204
Deceased name: William Erskine
Coroner name: Chris Morris
Coroner Area: Manchester South
Category: Alcohol, drug and medication related deaths
This report is being sent to: Ministry of Housing, Communities & Local Government
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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THIS REPORT IS BEING SENT TO: Rt. Hon. Michael Gove MP, Secretary of State for Levelling Up, Housing and Communities | |
1 | CORONER I am Chris Morris, Area Coroner for Manchester South. |
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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
3 | INVESTIGATION and INQUEST On 13th September 2023, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of William Erskine who died on 26th August 2023 on the Concourse of Stretford House, Chapel Lane, Stretford. The investigation concluded with an inquest which I heard on 22nd March 2024. A post-mortem examination conducted by [REDACTED], Consultant Pathologist on the Home Office Register, concluded that Mr Erskine died as a consequence of multiple injuries. At the end of the inquest, I recorded a conclusion of Misadventure. |
4 | CIRCUMSTANCES OF THE DEATH Mr Erskine died on 26th August 2023 on the concourse of Stretford House, Stretford, as a result of multiple injuries sustained when he fell or jumped from the open window of his 16th floor flat whilst his judgement was impaired through cocaine and alcohol use and following a recent violent altercation with his partner. A police investigation has concluded there was no third party involvement in his death. |
5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Mr Erskine was a resident of Stretford House, Chapel Lane, Stretford, M32 9AZ. Stretford House is a 23 floor residential block, comprising of 134 dwellings. The freehold owner of Stretford House is London and Quadrant Housing Trust, a Registered Provider of Social Housing. In the course of the evidence before the court, it was established that, whilst the windows in Mr Erskine’s flat were fitted with locks and dual-position window restrictors, the relevant restrictors can be released enabling the window to fully rotate within the frame (nominally to enable the resident to clean the glass). The degree to which the windows can be opened is therefore not restricted in the same way as if fixed window restrictors were fitted. It is a matter of concern that, aside from certain buildings designed for educational or healthcare use, or provided for vulnerable adults, current Building Regulations do not require fixed window restrictors to be fitted to opening windows in high-rise residential buildings; and In relation to windows of the type and design in use in Stretford House, there is no current requirement to retro-fit fixed window restrictors. |
6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 12th June 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. |
8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Mr Erskine’s daughter and his partner, and to Devonshires Solicitors LLP on behalf of London and Quadrant Housing Trust. I have also sent a copy to Trafford Metropolitan Borough Council who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 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: 17th April 2024 Signature: Chris Morris HM Area Coroner, Manchester South. |