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Clarion resident died after two weeks without heating
An 80-year-old Clarion Housing Group tenant suffered a fatal heart attack after living without heating or hot water for two weeks, an inquest has found.
Patricia Gavaghan died of cardiac arrest at her bungalow on Sycamore Road in Whittlesey on 22 December 2017, shortly after learning that no heating engineer would be coming to fix her boiler that day as promised by heating contractor Morgan Sindall.
But while bosses from Clarion and Morgan Sindall admitted that the service Ms Gavaghan received was “unacceptable”, assistant coroner Nick Moss said the organisations had since made improvements and concluded that further recommendations to prevent future deaths were not necessary.
Delivering a conclusion of death by natural causes yesterday at Huntingdon Law Courts, he noted “she was stressed and angered by the delay and by the lack of heating and hot water”.
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Medical experts concluded that the “cold, stress and anger” Ms Gavaghan experienced because of the failings were “possible” but not “probable” triggers for her heart attack, with severely clogged arteries meaning her condition was a “ticking time bomb”.
The grandmother of 19 had been living with only a halogen heater since 8 December, with a thermometer showing her home’s temperature as 9°C – the lowest level on its scale – while the Met Office had issued an amber weather warning for cold conditions.
Ms Gavaghan, who was described to the coroner as very independent and active, had repeatedly tried, along with her family members, to raise the issue with Morgan Sindall and Clarion from 11 December.
Clarion’s policy is for issues where tenants are left without heating to be rectified within 24 hours, or for temporary heaters to be provided when that is not possible.
The inquest heard that serious issues had emerged with Morgan Sindall’s contract to provide heating services for 15,000 Clarion homes in the region since it began in October 2017.
Ian Morrison, director of property services at Clarion, said the association gave Morgan Sindall a formal early warning notice to improve on 23 November and put an improvement plan in place, with the contractor declining an offer of sub-contractor support.
Mark Waterhouse, representing Morgan Sindall, said that call handlers were “unable to cope” with the volume of enquiries, receiving 6,079 in October compared with the 1,870 it expected.
Both Clarion and Morgan Sindall were aware of Ms Gavaghan’s age and the fact that she had no heating.
The landlord told the contractor it was “not acceptable” for her to wait two weeks for an appointment and asked for it to be brought forward.
A working log being passed between the organisations showed “dozens” of outstanding emergency cases, the inquest heard.
On the 22 December, the last working day before Christmas, Ms Gavaghan had been listed as an engineer’s last appointment of the day but he “ran out of time”, despite her family being assured in a call that morning that he would be attending.
After Ms Gavaghan’s death, Mr Morrison said Clarion told Morgan Sindall bosses at a meeting that the case was “so serious that the trust was broken”, and served a formal notice to terminate the contract on 8 January, as well as notifying the Regulator of Social Housing.
Clarion has now established a property engagement group with resident input and changed its procurement process to look at the robustness of bidders’ call handling and IT processes.
It also now starts heating contracts in summer and uses independent external audits to question 100 residents monthly about their satisfaction with their heating service, while making it easier to give services to other contractors more quickly.
Contractors are also now required to consider the vulnerability of callers.
Morgan Sindall has changed the software it uses to set engineers’ routes to prioritise emergency cases and has stopped using a national call centre.
And it has upgraded its IT systems to include more information about potentially vulnerable residents, also making it impossible for handlers to make emergency appointments for after 24 hours without managers issuing a jeopardy report.
Mr Moss said: “The information I have received satisfies me that a considerable amount of action has now been taken by both companies to deal with the potential for future occurrences.”
A spokesperson for Clarion said: “We were deeply saddened by the death of Mrs Gavaghan in December 2017.
“The safety and wellbeing of our residents is our priority.
“We were disappointed by the failure of our contractor Morgan Sindall to attend the property within 24 hours as contractually required, in case a repair had been needed.
"Clarion’s contract with Morgan Sindall for gas servicing and repairs was terminated by mutual agreement in February 2018.”
Morgan Sindall has been approached for comment.
