Kane Thomas Harley Davidson · Prevention of Future Deaths report

On 9 February 2022, Mr Matthew Cox, Assistant Coroner commenced an investigation into the death of Kane Thomas Harley Davidson.

On 28 January 2022, Kane Thomas Harley Davidson (Kane) was found unresponsive in the bedroom of his family home address ████████. Following attendance of the emergency services, he was transported to Royal Oldham Hospital. Clinical assessment rendered it necessary that Kane was transferred for specialist care at Royal Manchester Children's Hospital. Despite the sustained efforts of specialist clinicians, it was apparent that Kane had suffered extensive "widespread diffuse hypoxia pattern of ischaemic brain injury". Kane's physical condition declined and he sadly died on 1 February 2022. There is no evidence of suspicious circumstances or third party involvement in his death.

At the material time, the family lived in a privately rented property. The letting was managed on behalf of the landlord by professional letting agents. Prior to entering into that letting arrangement, the landlord had applied for and obtained a private licence from the Local Authority pursuant to section 88 of the Housing Act 2004. The licence was issued without prior inspection or audit of the proposed rental property. The issue of such a licence is predicated upon the basis that the landlord or appropriate licensed individual would continue to maintain the premises in a condition of safety from material hazards.

The window blinds at the property had-according to the landlord-been in situ for many years and before the date that Kane and his family moved into the property. They were not the subject of assessment for risk or review in advance of the residential letting arrangement to which Kane's parents were parties. The window blinds were not compliant with the British Standard EN13120 in that they did not incorporate the necessary safety features as required by those standards. Those standards are applicable, inter alia, to those homes where children under the age of 42 months are likely to be present.

1. The council has resolved to establish and implement a regime of landlord license registration pursuant to, inter alia, section 88 of the Housing Act 2004.

2. The resultant application process culminates in the grant of a license without any prior audit of the landlord's premises.

3. Where an audit of residential property is undertaken, there is no express obligation upon the person conducting the audit or assessment to refer to other risks to which children might be exposed, including, those posed by internal blinds.

4. This remains the position notwithstanding the fact that the council was on notice of such risk and indeed had issued guidance to those undertaking inspections. The nature and character of the risk posed by such equipment was not accommodated within any documentation to which the Court has been given access.

5. There is an absence of clarity as to the enforcement action, if any, to be taken by the Council in the event of a licence holder failing to comply with the conditions of the licence.

6. The form of certificate issued to landlords does not make sufficiently clear to actual or prospective tenants:

(1) that the issue of the certificate cannot and should not be taken as an endorsement of the premises to which the certificate relates;
(2) that the premises to which the certificate relates and/or in respect of which the landlord is licensed should not be assumed to be compliant with the relevant safety standards.

7. The conditions of licence are insufficiently clear in communicating the obligations upon the licence landlord and/or that the landlord remains personally liable for compliance with the licence conditions notwithstanding the use of any intermediary letting agency.