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L&Q sent letter by coroner after resident died of hypothermia following unanswered call about faulty boiler
A coroner in Manchester has issued under-fire landlord L&Q with an action to prevent future deaths report after an unanswered call about a faulty boiler was linked to an older resident who died of hypothermia.
Alison Mutch, senior coroner for Greater Manchester South, sent the ‘prevention of future death’ report to L&Q last week, after her findings revealed that resident Sylvia Pollitt’s concerns about her boiler were not escalated.
A coroner is able to issue a Regulation 28 Report under the Coroners and Justice Act 2009 to an individual, organisations, local authorities or government departments and their agencies where they believe that action should be taken to prevent further deaths.
The report shows that Mrs Pollitt had called L&Q to highlight a concern with her boiler. This was passed to a contractor, Liberty, which was sub-contracted to provide gas services but was unable to contact her and closed the call down.
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The coroner said “they should have escalated the situation” before Mrs Pollitt was found at her address in Seamons Walk on 1 December 2022, and a subsequent post-mortem examination found that she had died from complications of hypothermia.
This is in addition to gastrointestinal haemorrhage and acute gastric erosions.
Ms Mutch’s report said: “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 inquest heard evidence that where there is non-contact from a resident following a referral, then it should have been escalated back to the association so that it could carry out a welfare check and assess the next steps.
But this “did not happen in Mrs Pollitt’s case”, and the evidence showed that L&Q had no audit system that enabled it to know if this issue of non-escalation by Liberty was a one-off or a frequent issue.
L&Q has until 13 September to respond to the report and must set out the proposed actions to be taken.
David Lewis, executive group director of property services at L&Q, said: “We were extremely saddened by the death of Sylvia Pollitt, and our thoughts remain with her family, friends and neighbours. A tragic death like this must never happen again, and important changes have been made to ensure this is the case.
“After Mrs Pollitt reported a concern about her boiler, the job was passed to gas maintenance contractor Liberty. At this time, Liberty was under contract to Trafford Housing Trust (THT), a subsidiary of L&Q, and subject to THT processes.
“As the coroner’s report sets out, Liberty were unable to make contact with Mrs Pollitt, but rather than follow the agreed processes in place, they made no further efforts to access the property or let THT know about the situation.
“Prior to the inquest, L&Q undertook a thorough review of all call-outs put through to Liberty and did not find previous incidents where a similar incident had occurred. We did, however, immediately implement a stringent new process where we track the progress of each job every step of the way.
“We are able to audit every open, completed and aborted job, with reports produced on a weekly basis and reviewed between L&Q and Liberty managers. Any concerns are immediately escalated to our neighbourhood teams to undertake welfare checks. This is consistent with the recommendations made by the coroner in this case, which we are committed to learn from.
“More widely, following THT’s alignment with L&Q in April 2023, we are now replicating L&Q processes across all of our North West operations. Crucially, the L&Q process for repairs contractors does not permit them to cancel jobs without formal approval from L&Q. This will prevent such an incident from happening again.”
L&Q said it has also made a number of additional improvements following Mrs Pollitt’s death that includes how it manages and records the calls it receives about repairs, and more regular meetings with all contractors to monitor how the work they are doing for residents is progressing.
The landlord has referred itself to the Regulator of Social Housing in relation to this case.
For its part, Liberty said: “Everybody at Liberty is deeply saddened by the death of Sylvia Pollitt.
“On 18 November last year, a job was raised for a repair to a small leak on Mrs Pollitt’s boiler. We confirmed that the leak was not affecting the heating and hot water at Mrs Pollitt’s home and informed her we would make contact to schedule a repair. Unfortunately, in this case we were unable to contact Mrs Pollitt to arrange to visit her home.
“We are committed to working with L&Q to learn important lessons and implement changes to how services are delivered. Our thoughts and deepest sympathies remain with Mrs Pollitt’s family and friends.”
L&Q was today ordered to pay out £142,000 in compensation after a special investigation by the Housing Ombudsman uncovered a “prolonged period of decline” in its repairs and complaint-handling.
