Ian Leak · Prevention of Future Deaths report

On 25th April 2017, Alison Mutch OBE, Senior Coroner for Manchester South, commenced an investigation into the death of Ian Leak who was aged 59 when he died at his home address on 5th March 2017. The investigation concluded on the 10th August 2017.

The conclusion of the inquest was that Mr Leak died as a consequence of a fire in his flat, which was likely to have been started by a lit cigarette coming into contact with combustible material. At the end of the inquest, I recorded a conclusion of Accidental .
The medical cause of death was 1a) Fire Related Death II) Ischaemic Heart Disease.

Mr Leak had suffered from very poor health for a number of years. Having been diagnosed with a brain tumour, he endured some 15 brain operations, and experienced a number of strokes.

As a result, Mr Leak was left with significant disabilities. He had serious mobility problems, and his memory was affected. He could also become confused.
Mr Leak was a tenant at Peak Housing’s Honiton Oaks property, where he had his own flat.

On 5th March 2017, the fire service was alerted to a fire at Mr Leak's flat. The flat was entered and Mr Leak was tragically found to have died.

I heard evidence that Honiton Oaks was, at all material times, equipped with two fire alarm systems, both of which appear to have operated as intended in this case.

The first fire alarm system detects heat and / or smoke in communal areas and, if triggered, opens glass smoke vents and deactivates the lift having returned it to the ground floor. In accordance with the ‘Stay Put’ policy currently in operation of Honiton Oaks, whilst this system creates a visual alert on a fire control panel within the building, it does not trigger an audible fire alarm which other residents can hear.

The second system consists of combined heat and smoke detectors fitted in tenants’ individual flats. These generate an audible warning within the individual flat where the detectors have been triggered, but operates independently of the system covering the communal areas.

In the course of the inquest, I heard that as a result of planned upgrades to the Honiton Oaks alarm systems, from the end of this month, the communal system will be linked to an external monitoring service in addition to the internal panel.

I also heard evidence to the effect that Mr Leak was not the only tenant with mobility problems who resided at Honiton Oaks.

In such circumstance, the matter of concern is that in the light of the building’s ‘Stay Put’ policy, consideration should be given in the case of tenants who have particular mobility problems or are otherwise likely to have difficulty in escaping from a fire within the confines of their own flat, to arranging for external monitoring of the individual fire alert systems within those tenants’ flats.