In August 2023, Farleys represented the family of Luke Brooks, at a 4 day inquest at North Manchester Coroner’s Court in front of HM Senior Coroner Ms Joanne Kearsley.

Luke tragically died unexpectedly at his home address having been unwell with cold/flu symptoms for approximately a week. The medical cause of his death was confirmed as 1a) acute respiratory distress syndrome due to 1b) aspergillus pneumonia.

Background:

Luke resided at the family privately rented home in Oldham which the family had occupied since 2014.

Over the years they had numerous concerns as to the condition of the property which was cold and damp. In 2021 concerns had been raised to both the landlord and the environmental health department at Oldham Council by both the family and an early help service, Positive Steps.

Over the weekend prior to Luke’s death, he had several discussions with out of hours medical providers via the NHS 111 call line, a commissioned service run by the North West Ambulance Service (NWAS). Whilst the outcome of the calls had on 2 occasions suggested that Luke required a category 3 ambulance (attendance within 2 hours). Over that weekend the Inquest heard the wait time was 6-8 hours. Luke declined the same. On one occasion Luke asked whether he could take himself to A&E but was advised not to by the medical professionals.

On 25th October 2022, Luke woke as normal but within minutes started to seizure. The family responded immediately calling 999 with paramedics and air ambulance arriving 15 minutes later. Sadly Luke was pronounced dead that same day. Whilst the inquest found that Luke’s death could not be said to be have been caused by the damp and mould in the property, the inquest did reveal a number of serious concerns.

Coroners Concerns:

  1. The Coroner was deeply concerned that there was no register of private landlords available in England in contrast to other countries within the United Kingdom who have a national register. This meant that Local Authorities could be hampered in not knowing up to date address / contact details when they were made aware of concerns with a privately rented property. This is particularly important when the issue is one which is potentially life threatening e.g asbestos in a property or excessive damp.

  2. Additionally, the Coroner was concerned that NWAS had a local policy of advising people who described their symptoms of chest pain to not attend A&E on their own. Whilst NWAS have now revised this policy to remove this, it is not known if this could be set out in the local policies of other ambulance services.

The Coroner issued a prevention of future deaths report to:-

  1. Secretary of State for Levelling up, Housing and Communities (DLUHC)

  2. Secretary of State for Health

Department of Levelling up, Housing and Communities’ response:

Issue of no register of private landlords available in England:

  • The Renters (Reform) bill has been introduced to Parliament on 17th May 2023 – includes provisions for a new private rented sector database that will support the new Privately Rented Property Portal digital service.

  • Subject to parliamentary approval, all private residential landlords (letting property in England via an assured tenancy under the Housing Act 1988 or a regulated tenancy under the Rent Act 1977) will be legally required to register with the Property Portal, and to provide certain information relating to the properties they let – the service will help landlords understand their legal obligations and give tenants the information they need to make informed choices before entering into a tenancy agreement. The portal will also help landlords understand their legal responsibilities when letting property and provide renters with a new information source to see relevant information about a landlord and property. It will also allow local housing authorities to identify poor quality and non-compliant properties and who owns them, and take prompt action where appropriate.

Other actions of relevance:

  • Published comprehensive guidance on understanding and addressing the health risks of damp and mould in the home.

  • Wrote to Local Authority Chief Executives and council leaders setting out expectations they will take action to resolve poor housing in their area and directing them to provide information on housing conditions to the department.

  • Working towards introducing the Decent Home Standard to the sector.

  • A core element of decency is assessed by the Housing Health and Safety Rating System (HHSRS), the tool used to assess hazards in rented homes. Following review of the HHSRS, our summary report on the outcomes and next steps is available to view here.

  • An updated HHSRS that is accessible to landlords and tenants and efficient for local councils to use forms a vital part of our reforms to both the social and private rented sectors. New regulations to bring the findings of the review into force will be introduced after the conclusion of our review of the Decent Homes Standard.

In addition to representing the family of Luke Brooks under similar tragic circumstances, Farleys have also represented the family of 2-year-old Awaab Ishak. Awaab sadly passed away following prolonged exposure to mould and damp within his home, with the inquest revealing serious failings relating to Rochdale Boroughwide Housing and issues within social housing more generally.

Following Awaab’s death, Awaab’s Law was introduced in the landmark Social Housing Regulation Act 2023 which requires landlords to investigate and fix reported health hazards within specified time frames. The consultation on time frames was opened on 9th January 2024 and closed on 9th March 2024.

More information on Awaab’s Law can be found here.

The Coroner’s report issued to the Government following Luke Brooks’ inquest is another significant step forward in highlighting and addressing poor housing standards across social and private housing.

Department of Health and Social Care’s response:

The DHSC, on May 17, 2024, acknowledged the considerable delay in their response. They apologised and noted the Coroner’s concern regarding the NWAS policy advising against self-conveyance to A&E for chest pain. However, their response did not detail any further actions taken.

North West Ambulance Services’ response:

Whilst not the recipient of a report, NWAS addressed the following issues:

Policy Revision on Self-Conveyance:

  • The revised policy now provides that all exclusions for self-conveyance, save for Category 1 incidents, will be removed, and patients will be asked if they can make their own way to hospital. These changes to the Standard Operating Procedure (SOP) were approved by the 111 SOP review group and then by the 111 Quality Business Group (QBG).

Clarification of Ambulance Refusals:

  • The second point to address arose during evidence when a witness stated that Mr Brooks did not directly refuse an ambulance and only advised he was unable to make his own way to hospital.

  • The Coroner’s concern in this regard was fed back to the 111 service with the suggestion that advisors must be clear that a patient is refusing an ambulance disposition with this being confirmed directly with the patient, wherever possible. This guidance was also approved by the 111 SOP review group and then by the 111 Quality Business Group (QBG).

The Standard Operating Procedure (SOP), reflecting both above changes, went live on 5th September 2023 and the changes were communicated to staff via the 111 SharePoint site (OneSpace) in line with all SOP updates.

If you’re looking for legal representation at an inquest as you seek answers following the death of a loved one, please get in touch with Farleys’ inquest specialists on 0845 287 0939, by email, or through the online chat below.