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recurance

Ashleigh Timms

26 Apr 2022 · Coroner Graeme Irvine · East London

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. staff incompetence in fire evacuation

    “The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation”
  2. 2. non-compliant fire alarms

    “Fire Alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard Guidance”
  3. 3. unmanaged high-risk electrical devices

    “No clear and practical guidance exists on how specialist housing operators should manage the use of high-risk electrical devices such as portable electric fan heaters”
  4. 4. unclear digital lock guidance

    “No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing”
  5. 5. insufficient ARC connection emphasis

    “Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation”

Linked reports

Raised again laterPaul Hutchinson20 Apr 2026 · 4 years later
Closely relatedConfidence 0.85 · high

This report

“The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation”

Later report

“Staff training is not standardised for ECSA (or sheltered accommodation more generally) and may not include, for example, evacuation strategy, emergency evacuation plans, the use of telecare/fire alarm system and fire suppression systems”
Original on judiciary.uk ↗
Full chain: Inadequate staff training for fire evacuation in specialist housing

Responses

2022-0123-Response-from-Kennedys.pdf ↗· British Standards Institution

Stated action · annually

“Face to face fire safety training is now provided to staff. This training is provided annually by Pinnacle and is delivered at each premises. The training covers, amongst other things, evacuation routes and procedures, fire drills and fire safety measures. A copy of the training handbook provided to staff as part of that training is attached.”

2022-0123-Response-from-National-Fire-Chiefs-Council.pdf ↗· National Fire Chiefs Council

Stated action · earliest opportunity

“The NFCC undertakes, at the earliest opportunity, to seek to ensure that this Concern is reported into these committees to encourage debate and petition for such positive outcomes necessary, and as far as is achievable under this action by the NFCC, to, it is hoped, assuage your apprehension to this Concern.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error