Coroner issues warning about inadequate monitoring of fire risks in sheltered accommodation

On 21 January last year, Mr Hutchinson accidentally set himself alight by smoking. His smoke detector activated at 2.35pm that afternoon, but was silenced by a member of staff along with multiple other detectors.

The first call to London Fire Brigade came eight minutes later, and the manager of the accommodation did not contact the fire brigade until 2.50pm.

Following a finding of accidental death, West London assistant coroner Richard Furniss last month sent a prevention of future deaths (PFD) report to the Ministry of Housing, Communities and Local Government (MHCLG), the Local Government Association, the National Fire Chiefs Council (NFCC) and the Care Quality Commission raising three matters of concern.

First, he expressed concerns over existing fire safety regulations. “The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are private dwellings,” he wrote in the PFD report.

“The concern is that there is no specific requirement for a PCFRA (or a personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a requirement for emergency equipment and staff training and a timescale for regular reviews (including where the individual circumstances of a person in care change). This concern may apply to others in formal residential care.”

Second, Mr Furniss warned that staff training is not standardised for sheltered accommodation and may not include evacuation strategy, emergency evacuation plans, and the use of telecare/fire alarm systems and fire suppression systems.

Finally, he wrote that fire risk assessments for sheltered accommodation may not contemplate vulnerable residents as forming “any group of persons identified... as being especially at risk” under existing fire safety regulations.

“Vulnerable residents may be at special risk because of (for example) smoking or cooking practices and may have a compromised ability to self-evacuate,” the PFD report said.

“The concern is that fire risk assessments do not take this into account.”

PFD reports are issued when a coroner identifies a risk factor that could lead to people dying in future – they do not necessarily mean those factors caused the specific death covered in the inquest.

The recipients of Mr Furniss’ PFD report have until 16 June to respond.

The NFCC declined to comment in advance of sending a response to the coroner. MHCLG did not respond to a request for comment.