Source · Prevention of Future Deaths

Ashleigh Timms

Ref: 2022-0123 Date: 26 Apr 2022 Coroner: Graeme Irvine Area: East London Responses identified: 4 / 4 View PDF

Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.

Date 26 Apr 2022
56-day deadline 21 Jun 2022 est.
Responses identified 4 of 4
Emergency services related deaths (2019 onwards) Other related deaths

Coroner's concerns

AI summary
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.

Responses

4 respondents
London Fire Brigade Local Authority / Fire Service
26 Apr 2022 PDF
Action Planned

The LFB plans to conduct a regulatory audit of the premises, issue a clarification of LFB policy on vetting of fire safety audits, conduct a full review of training material for vulnerable sleeping risk premises and develop refreshed CPD, apply the new national scheme for third-party accreditation of fire safety inspecting officers, review guidance on portable electric fan heaters, highlight the issue to housing providers, and continue to press for guidance on fitting of digital keypads. (AI summary)

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Dear Mr Irvine,

REGULATION 28 PREVENTION OF FUTURE DEATH REPORT (1) REF: 108578 I am writing in response to your report dated 26 April 2022 (under the above reference) concerning the death of Ashlie Clare Liana TIMMS, which was initially sent to Deputy Assistant Commissioner Stephen Norman who gave evidence into the inquest. In your report you noted six areas of concern which were:
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm.
2. Fire alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
4. 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.
5. No clear guidance exists regarding the fitting of digital keypads on doors in specialist housing.
6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. It may be helpful to note at the outset, that for matters of concern numbered 4, 5 and 6, the Secretary of State for the Home Office is under a statutory duty in Article 50 of the Regulatory Reform (Fire Safety) Order 2005 (the FSO) to “…ensure that such guidance as he considers appropriate, is available to assist responsible persons in the discharge of their duties…”. Insofar as the matters of concern relate to parts of premises to which the FSO applies, it may be appropriate for these concerns to be drawn to the attention of Home Office ministers. My understanding is that the Home Office are currently engaged in a programme of refreshing national fire safety guidance documents that are used by both responsible persons and the authorities enforcing it. Similarly, the Secretary of State for the Department for Levelling Up, Housing and Communities has responsibility for the Housing, Health and Safety Rating System enforced by local authorities and which is applicable to the private domestic areas of many residential properties (where the FSO does The London Fire Commissioner is the fire and rescue authority for London

Date: 20 June 2022

not apply). The Secretary of State has a duty to provide guidance on the assessment of hazards and enforcement against them in section 9 of the Housing Act 2004 and also provides other guidance for landlords and property-related professionals. There is a need for all guidance on these matters to be co-ordinated, clear and readily available across all reasonable sources. Consequently, I would suggest that your concerns in this regard are also raised directly with the relevant Secretaries of State. I have addressed each of the matters of concern below:
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm. This raises a concern that premises management is not compliant with duties under the FSO, in particular the duty in Article 15 concerning appropriate procedures to be followed in the event of serious and imminent danger to relevant persons. The FSO is a self-compliance regime with the duty for compliance placed firmly with the responsible person. As the London Fire Commissioner, I have a duty to enforce those regulations. In enforcing the FSO my officers must act in accordance with the requirements of the statutory Regulators Code. LFB Fire Safety Inspecting Officers plan to attend the premises shortly after the end of the 56 day reply period to conduct a regulatory audit under the FSO. This will consider whether there is compliance with the FSO including Article 15.
2. Fire alarms in three units operated by Sequence Care Group remain non-compliant with the 2013 British Standard guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated. Regulators cannot directly enforce the recommendations of a British Standard unless it is cited as a required standard in relevant legislation or unless the arrangements actually in place can be shown to create a “risk gap” from the level expected by that standard. I understand the suggestion here was that the alarm did not include a link to an ARC because the premises had 24/7 staffing in place. LFB might consider this to be non-compliance with Article 13 of the FSO, although this would have to be considered in the light of the circumstances of an individual premises including the arrangements for staff training and testing of the arrangement. It would then be raised with the responsible person as part of any follow up to the regulatory audit. Making the recommendations of at least some British Standards directly enforceable is a matter that has been raised by other Coroners through regulation 28 reports with the relevant Secretaries of State, with support of the fire service. I would urge you to join them in to doing so.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete. I would firstly refer you to the statement of DAC dated 8 April 2022 and his live evidence to the inquest on 11 April 2022. In the year before the death of Ashleigh Timms, LFB had changed its policy on the vetting/review of fire safety regulatory audits by managers so as to include all audits of sleeping and vulnerable

sleeping accommodation regardless of the audit outcome. We have now undertaken a review of that element of policy and concluded that due to the ordering of paragraphs in the policy document a potential degree of ambiguity may have remained. That drafting has been addressed to place the matter beyond doubt and this has been promulgated to all staff working in the technical fire safety function. We have also amended our audit form to ensure improved justifications are stated for the overall scoring of an audit and for each article. This should better ensure there are records setting out exactly why the FSIO has deemed it to have been or complied with (or not). Over the course of the past two years LFB’s Central Regulatory Enforcement Group have been conducting bespoke training for regulatory fire safety team leaders on the management vetting of their team’s audit forms and Enforcement Notices to increase team leaders’ knowledge and skills. LFB has now brought in additional resources to assist with that and develop and roll out a new training package for all staff involved in the management vetting process. We expect to complete this over the course of the next six to twelve months. Deputy Assistant Commissioner Steve Norman drew your attention to work undertaken to educate staff on the risk arising in specialised housing and to our work running a series of external seminars for the managers of care homes. LFB’s Fire Prevention and Protection Department (P&P) are currently developing a new training needs analysis for LFB’s inspecting officers. Over the next six months P&P will conduct a full review of the training and continuous professional development (CPD) material used for all forms of vulnerable sleeping risk premises including care homes, extra care schemes and sheltered housing and supported living schemes. From this, over the next twelve months we will develop and roll out refreshed CPD covering the specific risks arising for these premises types. That CPD will be mandatory for all staff involved in the audit of these premises types and will form part of mandatory refresher training through our Development and Maintenance of Operational Professionalism (DaMOP) framework. LFB is also committed to applying the new national scheme of third-party accreditation of the competency of fire safety inspecting officers whose work involves the audit or provision of advice to higher risk premises. All such staff have achieved or are working towards an NVQ level 4 Diploma qualification after which they will be assessed though a new scheme operated by the Institution of Fire Engineers in conjunction with the Engineering Council. Achieving this level of accreditation for all Fire Safety Inspectors will take some time, potentially four to five years as there is currently a lack of approved assessors across the country. We expect the first tranche of Inspectors to be assessed over the coming 18 months.
4. 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.

Although there is some guidance contained in government approved and National Fire Chief Council guidance, we believe this is a matter that should be expanded on as part of the Government review of guidance to the public.

From the London Fire Brigade perspective, use of portable heaters forms part of the considerations under our home fire safety visits and the guidance documents we issue for fire safety in the home for example https://www.london-fire.gov.uk/safety/the-home/portable-heaters-gas-fires-and-open- fires/

We are currently reviewing our own guidance and I have instructed staff to include this issue in that review over the course of 2022.

We also operate a number of primary authority partnerships with housing providers and work with the G15 group of providers. Now that the inquest findings are available officers will highlight the issue to those we work with. However, you will recognise that under existing terms of lease or tenancy, the options for them to act in relation to their tenants may be limited and it is not something that my officers have a power to enforce.

5. No clear guidance exists regarding the fitting of digital keypads on doors in specialist housing.

Although there is some guidance contained in government approved and National Fire Chief Council guidance, I believe this is a matter that should be expanded on as part of the Government review of guidance to the public. However, the forms of locking devices used on the exit from a flat as a private dwelling is not something that falls to be regulated under the FSO. Therefore, LFB officers cannot enforce against it. This issue does arise from time to time in material and guidance produced in respect of ‘secure by design’. We will continue to press for guidance in that regard which does not adversely, or potentially adversely, inhibit escape from domestic premises in case of a fire emergency.

6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. The ethos of the FSO is one of risk-based fire safety preventative and protective measures. Under Government guidance that does mean that it is not a prescriptive regime. Alternative means can be used to demonstrate compliance rather than adherence to a British Standard. As an enforcing authority we use British Standards as the benchmarks of good practice. However, we cannot necessarily enforce them unless a demonstrable risk arises from failing to comply with them. If that were to be the case, then we can and will continue to direct that the appropriate British Standard is followed. However, that cannot be done if alternative means to the recommendations of the British Standard (or other guidance) have been used and are found, on the day of inspection, to apparently be providing an equivalent level of safety. In the latter circumstances an enforceable level of risk would not have been identified and so a direction could not be given under article 30 of the RRFSO. The issue appears to be a lack of a direct enforcement mechanism for British Standards. That is a matter my officers have previously raised through the coronial system and with government. If a specific requirement is to be enforceable it will require legislative change. We will continue to advocate for this in appropriate cases as part of our ongoing work with government, other regulators and the sector itself. To summarise, along with the action already taken, LFB intends the following further actions:
1. Officers plan to attend the premises shortly after the end of the 56 day reply period to conduct a regulatory audit under the FSO.

2. A clarification of LFB policy expanding the requirement for vetting/review of fire safety regulatory audits by managers is to be issued to officers in the next few weeks.

3. Over the coming six months LFB will conduct a full review of the training and continuous professional development material used for all forms of vulnerable sleeping risk premises

including care homes, extra care schemes and sheltered housing and supported living schemes.

4. From this work in point 3, over the course of the next twelve months LFB will develop and roll out refreshed CPD covering the specific risks arising for these premises types.

5. LFB is committed to applying the new national scheme of third-party accreditation of the competency of fire safety inspecting officers whose work involves the audit or provision of advice to higher risk premises. We expect the first tranche of Inspectors to be subject to assessment over the coming 18 months.

6. Over the course of 2022 we will review our own guidance offering concerning portable electric fan heaters in premises such as these.

7. We operate a number of primary authority partnerships with housing providers and work with the G15 group of providers. LFB officers will highlight the issue of the use of high-risk electrical devices such as portable electric fan heaters to those providers we work with.

8. We will continue to press for guidance on fitting of digital keypads on doors in specialist housing that will not adversely, or potentially adversely, inhibit escape from domestic premises in case of a fire emergency. I hope that this satisfactorily explains the actions that have been taken and those which we will continue to take to address the concerns raised in your letter.
National Fire Chiefs Council Other
15 Jun 2022 PDF
Action Planned

The NFCC will report the coroner's concerns to BSI committees (FSH12 and FSH14) to encourage debate and petition for positive outcomes, and will continue to work with the Home Office to ensure the matter of Concern is suitably addressed in any Guidance revision. (AI summary)

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Dear Sir, Coroners and Justice Act 2009 Coroners (Investigations) Regulations 2013 Regulation 28: Report to Prevent future deaths (Ref: 108578) Re: Ashlie Claire Liana Timms, deceased As requested, I write in response to the above-mentioned report (Report) and particularly the concerns (Concerns) you have raised therein. By way of background, the National Fire Chiefs Council (NFCC) is the professional voice of the UK fire and rescue services (FRS) and is comprised of a council of UK chief fire officers. The NFCC is a membership organisation of FRS senior and strategic managers. Its main aims are to support FRS to meet the changing demands on resources and to maximise effectiveness by promoting consistency by highlighting best practice in the sector.1 For the sake of clarity, the NFCC is not an enforcing authority under the principal fire regulations relevant to the premises in issue; it does not have regulatory functions. The principal fire regulations applicable to the premises can be found in the Regulatory Reform (Fire Safety) Order 2005 (the Order).2 Article 25 of the Order provides—for the purposes of the Order—the meaning of an ‘enforcing authority’. One of the enforcing authorities within Article 25, is the fire and rescue authority, which is the corporate entity of the FRS pursuant to Section 1 of the Fire and Rescue Services Act 2004 (as amended),3 in which the premises are located.

1 Further information can be found here: National Fire Chiefs Council (NFCC) 2 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 3 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk)

15 June 2022

Enforcing authorities are required to enforce the provisions of the Order and any regulations made under Article 24 in relation to premises for which they are the applicable enforcing authority.4 In doing so, they must have regard [emphasis added] to guidance issued by the Secretary of State.5 Further reference to this statutory guidance is amplified hereunder. The NFCC, whilst not an enforcing authority under the Order, is able to contribute, encourage and steer, within reason, the strategic and operational functions, and activities of FRS, as they relate, among other things, to fire safety and protection, and the relevant statutory duties to enforce the Order. The following is provided to take account of each Concern. This regrettably requires, for the avoidance of doubt, repetition. The NFCC considers this favourable to assist with, among other things, future integrity of this response, should this document be later fragmented by design, or otherwise, and reproduced elsewhere. For ease of reference, the following uses the same numbering for Concerns as set out in the Report.
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm. The NFCC replaced the Chief Fire Officers Association (CFOA) which were a participant in the production of HM Government Fire Safety Risk Assessment in Residential Care Premises
20076. This document recognises, among other things, that relevant practical staff training, in evacuation procedures in the event of a fire, is vital in environments where residents of care homes have complex physical, sensory, and cognitive needs. In 2017 the NFCC, along with many stakeholders, co-operated to produce the Fire Safety in Specialised Housing Guide7. This document provides guidance on evacuation in supported living and other specialised housing. The NFCC represent FRS on various British Standards Institute (BSI) committees and other groups such as National Social Housing Fire Safety Group. Further, and perhaps more importantly in this case, the NFCC meet with the Care Quality Commission and other interested parties, regarding fire safety standards in higher risk accommodation. Action
1. 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.

4 Article 26 Regulatory Reform (Fire Safety) Order 2005 5 Article 26(2) Regulatory Reform (Fire Safety) Order 2005 6 See: Fire safety risk assessment: residential care premises - GOV.UK (www.gov.uk) 7 See: NFCC_Specialised_Housing_Guidance_-_Copy.pdf (nationalfirechiefs.org.uk)

15 June 2022

2. The NFCC will send a copy of your Report annexed to a copy of this response, to all FRS in England to bring your Concerns to their respective attention, and to inform the FRS of the NFCC’s proposed actions. This should provide an excellent opportunity to direct information regarding the Concerns and the NFCC’s response, into the corporate mind and strategic management forums of the FRS.
2. Fire alarms in three units operated by Sequence Care Group remain non-compliant with the 2013 British Standard Guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when an alarm is activated. The NFCC represent FRS on BSI committees including the overarching committees for fire detection and alarm systems (FSH12) and fire precautions in buildings (FSH14). Action
1. The NFCC undertakes, at the soonest 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.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findings were found to be entirely incongruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete. The former CFOA provided the audit framework that FRS adapt to their own local working practices. This is reviewed regularly and is now due for a full review and improvement following the recent introduction of new fire related legislation which will affect the FRS audit process.8 The NFCC is heavily involved with the, relatively new, Fire Standards Board (FSB). The FSB was founded to oversee the identification, organisation, development, and maintenance of professional standards for fire and rescue services in England. The FSB is responsible for approving standards and the approach to their development. It sets the priorities for standards development work. And commissions work based on proposals from third parties, monitors progress with ongoing work and approves completed work. Further, it seeks to ensure that any standards presented for approval have been developed in line with the agreed development process, undergone appropriate consultation with subject matter experts and relevant stakeholders and undergone an independent quality assurance process. The FSB meets at least four times per year; all papers are published on its website.9

8 See: Fire Safety Act 2021 (legislation.gov.uk) and Building Safety Act 2022 (legislation.gov.uk) 9 See: Fire Standards Board

15 June 2022

Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS)10 independently assesses and reports on the effectiveness and efficiency of FRS. The HMICFRS draws upon its inherent expertise to interpret the evidence derived from the assessments of FRS to make recommendations for improvement. Action
1. The NFCC will redouble its efforts in progressing such work mentioned above and that it is responsible for. This extends to influencing the content of new or amended fire protection and safety standards. The NFCC is also currently leading the review of the competency framework for Fire Safety Regulators (which includes FRS inspecting and enforcement officers) and enforcement toolkit for high rise buildings and have in the past year launched a third-party professional accreditation scheme for Fire Safety Regulators and a national learning platform to underwrite the continual professional development of such officers.
2. The fire sector, in the wake of the Grenfell fire tragedy, is receiving the closest of scrutiny, review and reform—much of which is being driven by HM Government—and the NFCC is subject to the dynamic and varying demands and challenges flowing from these activities. The NFCC respectfully submits, therefore, that there is some difficulty in offering a timetable to complete this action, other than to say that it is receiving dedicated and continual attention by the NFCC, with an expectation of delivery within the upcoming months.
3. The NFCC will continue to support the FSB with its undertakings.
4. The NFCC will continue to support the HMICFRS with its undertakings.
4. 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. Pursuant to Article 50 of the Order,11 the Secretary of State must ensure that guidance (Guidance) is issued to assist those responsible for fire protection and fire safety within premises to which the Order applies. A full review and improvement of the Guidance is in progress and is being superintended by the Home Office. Notwithstanding this, it is the view of the NFCC that the Guidance, regarding care homes and the NFCC Specialised Housing Guide, whilst not being statutory in nature, does satisfactorily address this Concern.12 Action
1. The NFCC is in the process of carrying out a significant programme of work, much of which is closely aligned and in collaboration with, the Home Office and the Department for Levelling Up, Housing and Communities. It is also working closely with the Care Quality Commission13 to formalise the use of ‘Person Centred Fire Risk Assessments’ (PCFRA) by care provider companies as part of care planning processes. Similarly,

10 See: HMICFRS - Home (justiceinspectorates.gov.uk) 11 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 12 See: NFCC_Specialised_Housing_Guidance_-_Copy.pdf (nationalfirechiefs.org.uk) 13 See: Care Quality Commission (cqc.org.uk)

15 June 2022

local authorities, housing providers and their fire risk assessors are being encouraged to apply PCFRA to new residents upon the granting of leases or periodic tenancies. The NFCC believe these innovative interventions will increase the likelihood of such risks being identified and addressed in future.
2. This work includes the Guidance review and improvement, and the NFCC will continue to work with the Home Office to make sure that the matter of Concern is suitably addressed in any Guidance revision. It should be noted that any revision is subject to drafting and consultation, with an expectation of being issued in early 2023.
5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing. Pursuant to Article 50 of the Order,14 the Secretary of State must ensure that guidance (Guidance) is issued to assist those responsible for fire protection and fire safety within premises to which the Order applies. A full review and revision of the Guidance is in progress and is being superintended by the Home Office. Notwithstanding this, it is the view of the NFCC that its own guidance, contained in the NFCC Specialised Housing Guide, whilst not being statutory in nature, does satisfactorily address this Concern. Action
1. The NFCC is in the process of carrying out a significant programme of work, much of which is closely aligned and in collaboration with the Home Office and the Department for Levelling Up, Housing and Communities.
2. This work includes the Guidance review and improvement, and the NFCC will continue to work with the Home Office to make sure, as far as is reasonably practicable, that the matter of Concern is suitably addressed in any Guidance revision. It should be noted that any revision is subject to drafting and consultation, with an expectation of being issued in early 2023.
6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. The NFCC represent FRS on BSI committees including the overarching committees for fire detection and alarm systems (FSH12) and fire precautions in buildings (FSH14). Action
1. The NFCC undertakes, at the soonest 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 assuage your apprehension to this Concern.

14 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk)

15 June 2022

Conclusion In closing I wish to provide you with my assurance that the NFCC will attend to, and expedite the actions set out above, with due diligence, care, and close attention. I trust that you find all in order with this response and that you consider the NFCC proposed actions contained herein—as far as they can be addressed by the NFCC—suitable in addressing the Concerns. And, further, that you are satisfied that the relevant duty for the NFCC to respond to your Report has been properly discharged. If this is not the case or, if you require anything further from the NFCC, please do not hesitate to contact my colleague Roy Carter within the NFCC Protection Policy and Reform Unit .
Kennedys
16 Jun 2022 PDF
Action Taken

Sequence Care has revised its competency checklist, re-assessed staff against it, arranged additional training sessions and updated fire alarms in homes to link to an Alarm Receiving Centre (ARC); ARC links at two homes will be completed by 24 June 2022. (AI summary)

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Dear Sir, PREVENTION OF FUTURE DEATHS REPORT FOLLOWING THE INQUEST INTO THE DEATH OF MS ASHLIE TIMMS We write further to the conclusion of the inquest into the death of Ms. Ashlie Timms, and the subsequent circulation of a Prevention of Future Deaths report, dated 26 April 2022, by HM Senior Coroner, Graeme Irvine (“the Report”). The Chief Operating Officer (and Acting Chief Executive Officer) of Sequence Care, Robert Dalrymple, provided two statements to the Inquest on behalf of the organisation, dated 7 April 2022 (“First Statement”) and 11 April 2022 (“Second Statement”). These statements outlined the remedial measures taken by Sequence Care since Ms. Timms’ death. Sequence Care as an organisation is determined to learn all the lessons it can from the recently concluded Inquest proceedings. Sequence Care has reviewed the contents of the Report and can update HM Senior Coroner on the following concerns.
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation. Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest remained unable to describe the proper action to take in the event of a fire alarm. Kennedys is a trading name of Kennedys Law LLP. Kennedys Law LLP is a limited liability partnership registered in England and Wales (with registered number OC353214). Kennedys offices, associations and cooperations: Argentina, Australia, Belgium, Bermuda, Bolivia, Brazil, Canada, Chile, China, Colombia, Denmark, Dominican Republic, Ecuador, England and Wales, France, Guatemala, Hong Kong, India, Ireland, Israel, Italy, Mexico, New Zealand, Northern Ireland, Norway, Oman, Pakistan, Panama, Peru, Poland, Portugal, Puerto Rico, Scotland, Singapore, Spain, Sweden, Thailand, Turkey, United Arab Emirates, United States of America. A list of Partners is available for inspection at our registered office at 25 Fenchurch Avenue, London EC3M 5AD. Kennedys Law LLP is authorised and regulated by the Solicitors Regulation Authority. We use the word ‘Partner’ to refer to a member of Kennedys Law LLP, or an employee or consultant who is a lawyer with equivalent standing and qualifications.

Steps were already being taken by Sequence Care to address the Coroner’s concerns in this regard prior to the conclusion of the Inquest, as detailed in paragraphs 26 to 28 of Mr First Statement. In light of the Report, Sequence Care can now provide the following additional information to HM Senior Coroner in respect of each of these paragraphs as follows:
26. 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. The face to face fire safety training provided by Pinnacle is specifically fire warden training. By training all its permanent staff to this level, Sequence Care aims to ensure that there will always be a fire warden trained member of staff on duty at any one time. Sequence Care continues to provide e-learning to all permanent staff via an external third party (Care Skills Academy). However this is limited to an employee’s induction to the company and is supplementary to specific face to face induction training delivered at each home (see below in respect of paragraph 27 of Mr First Statement). The face to face fire warden training is provided to all employees annually via Pinnacle, and any new joiners will be added on to the next available session to supplement their e-learning. Further training sessions are also being carried out to ensure that any remaining staff are provided with outstanding training (see below).
27. Specific induction training, tailored to each of Sequence Care’s premises, is also provided to the permanent and agency staff assigned to work there. This training is delivered to staff by either the registered manager or one of the deputy managers. The training ensures staff are familiar with and have read the following: fire safety policy, accidents and incidents procedure, EMG Response Plan and support plans/risk assessments/PEEPs for service users at that premises. Completion of this training is confirmed in the permanent and agency staff checklists attached…Staff refresher training is also provided annually. Sequence Care provided HM Senior Coroner with copies of the induction checklists for the training of both permanent and agency staff. The provision of annual fire warden training (see above) aims to ensure that there will always be a fully trained permanent member of staff on duty at any given time.
28. In addition, a competency assessment is carried out on an annual basis by either the registered manager or deputy manager (who are also to be trained by SOCOTEC in how to carry out this assessment) in the form of question and answer sessions, on which staff 2 of 4

are assessed. This ensures management monitoring of staff training. A copy of the competency assessment checklist is attached at Exhibit RD/18. Face to face fire safety competency checks take place at individual homes on an annual basis. The competency checklist questions were revised upon the conclusion of the Inquest. The updated checklist was attached as the above referenced exhibit to Mr First Statement, with the additional questions highlighted in red. Staff have been re-assessed against the revised competency checklist following the conclusion of the Inquest. Please refer to the enclosed spreadsheet which records the completion of the competency assessment training – and all outstanding training - by staff members. Sequence Care has arranged additional sessions to address the training in outstanding areas.
2. Fire alarms in three units operated by Sequence Care Group remain non-compliant with the 2013 British Standard Guidance, which recommends that they should have a link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire alarm is activated. As outlined in Mr First Statement, Sequence Care had already taken steps to ensure that the fire alarms in all but three of its homes were linked to an Alarm Receiving Centre (“ARC”). The Second Statement confirmed that, at that time, there were three homes within the Group which did not have fire alarm systems linked with an ARC as recommended in British Standards BS 5839-1. Whilst the three homes did not adhere to the guidance provided by the British Standards, it is not correct to say that they were non-compliant. Sequence Care has now arranged for the fire alarm systems at these homes to be updated so that they are compatible and for an ARC link to be installed. Details of the current status of these three homes are as follows:
i.
– works completed and system (including ARC) activated on 20 May 2022;
ii.
– works due to be completed on 24 June 2022, the delay being due to the implementing team being absent due to Covid-19;
iii.
– works due to be completed on 24 June 2022, the delay being due to the implementing team being absent due to Covid-19. 3 of 4
British Standards Institution Regulator / Inspectorate
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Action Planned

BSI's committee FSH/12 will pass on concerns to technical committee FSH/14 and sub-committee FSH/12/1, who will consider the issues and update progress in due course; the sub-committee FSH/12/4 may consider the issue of electronic locking as part of a forthcoming amendment to BS 7273-4. (AI summary)

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T o: C or o n er s C c:

S u bj e c t: R ef 1 0 8 5 7 8 F A O Mr G Ir vi n e P RI V A T E A N D C O N FI D E N TI A L D a t e: 1 5 J u n e 2 0 2 2 1 2: 0 2: 1 7 A t t a c h m e n t s:

D e ar Sirs, Pl e as e f or w ar d t h e b el o w t o Mr G Ir vi n e, A cti n g S e ni or C or o n er D e ar Sir F urt h er t o o ur e m ail of 5 M a y, I a m writi n g t o u p d at e y o u o n B SI’s r es p o ns e t o y o ur R e g 2 8 r e p ort. M e m b ers of B SI’s c o m mitt e e F S H/ 1 2 - Fir e d et e cti o n a n d al ar m s yst e ms h a v e dis c uss e d y o ur R e g 2 8 r e p ort. T h e c o m mitt e e e x p erts b eli e v e t h e c o m mitt e es w hi c h s h o ul d e x a mi n e t h e iss u es m or e cl os el y ar e:
a. T e c h ni c al c o m mitt e e F S H/ 1 4 - Fir e pr e c a uti o ns i n b uil di n gs. T h e s c o p e of t h e c o m mitt e e is “t h e d e v el o p m e nt of N ati o n al st a n d ar ds f or fir e s af et y pr e c a uti o ns i n r esi d e nti al a n d c o m m er ci al b uil di n gs, fir e ris k ass ess m e nt a n d fir e ris k m a n a g e m e nt s yst e ms. ” A m o n g ot h er st a n d ar ds, F S H/ 1 4 is r es p o nsi bl e f or B S 9 9 9 1 Fir e s af et y i n t h e d esi g n, m a n a g e m e nt a n d us e of r esi d e nti al b uil di n gs - C o d e of pr a cti c e. T h at st a n d ar d is c urr e ntl y b ei n g r e vis e d, a n d is d u e t o g o f or p u bli c c o ns ult ati o n o n 2 1 J ul y 2 0 2 2.
b. S u b c o m mitt e e F S H/ 1 2/ 1. T h e s c o p e of t h e c o m mitt e e is: “I nst all ati o n a n d S er vi ci n g - t h e d e v el o p m e nt a n d m ai nt e n a n c e of Britis h St a n d ar ds a n d t h e U K i n p ut i nt o C E N/ T C 7 2, I S O/ T C 2 1/ S C 3 a n d t h eir W or ki n g Gr o u ps i n t h e ar e a of pl a n ni n g, d esi g n, i nst all ati o n a n d s er vi ci n g of s yst e ms ”. A m o n g ot h er st a n d ar ds, F S H/ 1 2/ 1 is r es p o nsi bl e f or B S 5 8 3 9- 1: 2 0 1 7 Fir e d et e cti o n a n d fir e al ar m s yst e ms f or b uil di n gs - C o d e of pr a cti c e f or d esi g n, i nst all ati o n, c o m missi o ni n g a n d m ai nt e n a n c e of s yst e ms i n n o n- d o m esti c pr e mis es, a n d B S 5 8 3 9- 6: 2 0 1 9 + A 1: 2 0 2 0 Fir e d et e cti o n a n d fir e al ar m s yst e ms f or b uil di n gs - C o d e of pr a cti c e f or t h e d esi g n, i nst all ati o n, c o m missi o ni n g a n d m ai nt e n a n c e of fir e d et e cti o n a n d fir e al ar m s yst e ms i n d o m esti c pr e mis es. F S H/ 1 2/ 1 m et o n 1 0 J u n e, a n d h a v e i d e ntifi e d t h e f oll o wi n g as p e cts of B S 5 3 8 9- 1 t o b e c o nsi d er e d as p art of a f ut ur e r e vi e w, a n d als o t o b e c o nsi d er e d i n r es p e ct of B S 9 9 9 1 b y F S H/ 1 4:
1. W h et h er B S 5 8 3 9- 1 s h o ul d i n cl u d e u n d er us er r es p o nsi biliti es a n i nf or m ati v e n ot e t h at t h e us er m a y wis h t o r e q u est a c o m pl et e r e vi e w of t h e “ a d dr ess es ” of fir e d et e ct ors at r e g ul ar i nt er v als, f or e x a m pl e, 5 y e ars.
2. W hil e B S 5 8 3 9- 1 alr e a d y d et ails a n e e d f or us ers of t h e st a n d ar d t o c h e c k z o n es a n d c o nfir m z o n e pl a ns, it is pr o p os e d t h at c o m m e nt ar y b e a d d e d t o 4 6. 2 a n d/ or 2 3. 1 m a ki n g t h e ris k t o lif e fr o m a l a c k of a z o n e pl a n v er y cl e ar. T h e t e xt c o ul d als o list t h e l a c k of a z o n e pl a n as a m aj or n o n- c o nf or mit y O R t h e l a c k of a z o n e pl a n i m m e di at el y r e n d eri n g t h e s yst e m n o n- c o m pli a nt. T his m a y i n cl u d e t h e a bs e n c e of a n A R C.
3. R e g ar di n g A R C c o n n e cti o ns, t h e c o m mitt e e n ot e d, m a n y Fir e & R es c u e S er vi c e ( F R S) ar e o p er ati n g a nil-r es p o ns e p oli c y t o A F As ( A U T O M A TI C FI R E A L A R Ms). T h e st a n d ar d m a y i n cl u d e a r e c o m m e n d ati o n t h e us er t o d et er mi n e w h at t h e p oli c y is f or t h e l o c al F R S a n d c o nfir m w h et h er t h e pr e mis es ar e i n cl u d e d or e x e m pt.
4. C urr e ntl y t h e st a n d ar d all o ws v ari ati o ns t o b e m a d e a n d t h e s yst e m still b ei n g c o nsi d er e d c o m pli a nt. T h e c o m mitt e e h as pr o p os e d t h e cr e ati o n of a list of c ert ai n v ari ati o ns t h at c a n n ot b e all o w e d, a n d t h at s yst e m still b e c o nsi d er e d c o m pli a nt. T h e n e e d t o j ustif y t h e

v ari ati o n(s) m a y als o b e i n cl u d e d i n t h e cl a us e.
5. W h et h er a n i nf or m ati v e n ot e b e i n cl u d e d t h at st at es a n al ar m c a n n ot b e r es et u ntil t h e c a us e of t h e al ar m is r es ol v e d. H o w e v er, it w as n ot e d a n y n e w w or di n g w o ul d b e a d d e d t o cl a us es p ert ai ni n g t o us er o p er ati o n r at h er t h a n a n y n e w r e c o m m e n d ati o ns f or m a n uf a ct ur ers.
6. T h e c o m mitt e e is c o nsi d eri n g i n cl u di n g a r e c o m m e n d ati o n t h at t h e e v e nt l o g s h o ul d b e l ar g er. H o w e v er, t h e y n ot e d t h at o n e iss u e is t h at “ e v e nt ” is v er y br o a d. As p art 1 is a C o P, t h er e ar e li mits t o w h at c a n b e r e c o m m e n d e d a n d a E N 5 4 pr o d u ct st a n d ar d m a y b e b ett er pl a c e d. T h er e ar e als o t e c h ni c al li mit ati o ns. It h as b e e n pr o p os e d t h at t e xt b e a d d e d t o c o m m e nt ar y t h at p oi nts o ut t h at m a xi m u m n u m b er of r e c or d a bl e e v e nts is 9 9 9 b ut m or e m a y b e n e e d e d, a n d t h o u g ht s h o ul d b e gi v e n t o pr o vi di n g m or e c a p a cit y f or a d dr ess a bl e s yst e ms. It w as als o a gr e e d t h at B S 5 8 3 9-6: 2 0 1 9 + A 1: 2 0 2 0 n e e ds t o b e r e vi e w e d a g ai nst t h e a b o v e list as t h es e c h a n g es m a y n e e d t o b e m a d e t h er e. It w as s u g g est e d t h at B SI m a y n e e d t o writ e t o or i nf or m all Fir e a n d R es c u e S er vi c es a n d p ossi bl y t h e C ar e Q u alit y C o m missi o n ( C Q C) t o i nf or m t h e m of t h e c h a n g es t o t h e st a n d ar d t o e n c o ur a g e att e n d a n c e t o A F As d uri n g t h e d a yti m e. It w as f urt h er s u g g est e d t h at t h e f a mil y of t h e d e c e as e d b e i nf or m e d as t o t h e pr o p os e d c o urs e of a cti o n b y t h e r el e v a nt a ut h orit y/ or g a niz ati o n. R e g ar di n g t h e m att er of k e y l o c ks, it w as a gr e e d s u b c o m mitt e e F S H/ 1 2/ 4 m a y c o nsi d er it as p art of a f ort h c o mi n g a m e n d m e nt t o B S 7 2 7 3- 4. It m a y als o b e c o v er e d as p art of t h e o n g oi n g r e visi o n of B S 9 9 9 1 vi a t h e i n cl usi o n of a n i nf or m ati v e n ot e t o t h e eff e ct t h at “if el e ctr o ni c l o c ki n g is pr o vi d e d o n fl at e ntr a n c e d o ors of i n di vi d u al u nits of a c c o m m o d ati o n it s h o ul d n ot b e n e c ess ar y or n e e d e d t o i nst all a c o d e t o e xist t h e fl at. M e a ns of el e ctri c l o c ki n g s h o ul d b e si m pl e a n d e as y t o us e ( e g a si m pl e l e v er h a n dl e). It is als o i m p ort a nt t h at r esi d e nts u n d erst a n d h o w t o us e t h e el e ctr o ni c l o c k. ” Fi n all y, it w as als o s u g g est e d t h at B S 9 9 9 1 c o ul d s a y t h at “ c o nsi d er ati o n s h o ul d b e gi v e n f or A R C c o n n e cti o n i n c ert ai n s u p p ort e d h o usi n g ” a n d f urt h er g ui d a n c e c a n b e f o u n d i n B S 5 8 3 9 -1. E a c h of t h os e p oi nts will b e c o nsi d er e d b y t h e r es p o nsi bl e c o m mitt e e(s) a n d w e will writ e a g ai n t o u p d at e pr o gr ess i n d u e c o urs e. Y o urs si n c er el y,

B A/ L L B ( H o n s) H e a d of St a n d ar d s G o v er n a n c e B SI, 3 8 9 C hi s wi c k Hi g h R o a d, L o n d o n, W 4 4 A L, U K

W e s u p p ort t h e U N S u st ai n a bl e D e v el o p m e nt G o al s, s o pl e a s e c o n si d er t h e e n vir o n m e nt b ef or e pri nti n g t hi s e m ail T h e Briti s h St a n d ar d s I n stit uti o n i s a m e m b er of B SI Gr o u p a n d i s i n c or p or at e d i n E n gl a n d u n d er R o y al C h art er. It s pri n ci p al a d dr e s s i s 3 8 9 C hi s wi c k Hi g h R o a d, L o n d o n, W 4 4 A L, U nit e d Ki n g d o m

Report sections

Investigation and inquest
On 20th April 2018 Ms Nadia Persaud opened an investigation touching upon the death of Ms Ashlie Claire Liana Timms Ms Persaud opened an inquest on 1st June 2018, the inquest was heard, before a jury commencing on 21 st March 2022 and concluding on 12th April 2022. The jury arrived at a narrative conclusion. "Ashlie Claire Liana Timms died from the effects of burns and inhalation of fire products on 20 April 2018, whilst a resident within a supported living setting at 20 B Connington Crescent Chingford London. Due to the ignition of fabric materials by a fan heater, a significant fire developed within the premises. The presence of a fire detection system, which was not installed to alert the emergency services, alerted staff employed to support and care for residents, to the presence of the fire . As a result of staff interpreting the address location on the alarm display, which was known by the wider organisation to be incorrect, staff departed from basic fire evacuation procedures. This resulted in up to a 45 minute delay to summon emergency services, demonstrating a significant lack of urgency to do so. With the additional actions of staff resetting the fire alarm on at least two occasions and the absence of implementing the deceased's personal emergency evacuation plan, the deceased was not evacuated. The presence of an electronic code disabling locking mechanism for the deceased to navigate, at the main point of escape, presented additional obstacles for the deceased in an already highly stressful situation. All of which contributed towards her death. With the absence of an effective fire safety audit in 201 7. The discovery of departures from British fire standards and recommendations, conflicting organisational fire policies and fire risk assessments went unchallenged. All areas identified above, in combination with the lack of a bespoke fire related policy and fire risk assessments contributed towards her death. " The medical cause of death was found to be;
1.a. Burns and inhalation of the products of fire CIRCUMSTANCES OF THE DEATH Ashlie Timms was a 46 year old woman who lived in a self-contained flat in a supported accommodation unit. Ms Timms suffered from, physical disabilities, a moderate learning disability, and a borderline personality disorder. On 20th April 2018, a fire broke out in Ashlie's bedroom at a time between 01 .30 and 02.00 hrs. The most likely cause of the fire was combustible material coming into contact with a portable electric fan heater located near the foot of Ashlie's bed.
Circumstances of the death
Ashlie Timms was a 46 year old woman who lived in a self-contained flat in a supported accommodation unit. Ms Timms suffered from, physical disabilities, a moderate learning disability, and a borderline personality disorder. On 20th April 2018, a fire broke out in Ashlie's bedroom at a time between 01 .30 and 02.00 hrs. The most likely cause of the fire was combustible material coming into contact with a portable electric fan heater located near the foot of Ashlie's bed. Fire detectors in Ashlie's room triggered a fire alarm system which sounded in the unit. Staff at the unit inspected the fire alarm panel which directed them to a room at the opposite side of the building to Ashlie's flat. Staff did not evacuate the building or call for the emergency services in contravention of the operator's policies and national guidance. The fire alarm in the unit was not capable of automatically calling the fire and rescue services. Staff searched the premises for signs of a fire and when they were unable to locate smoke or flames, they reset the fire alarm. Staff later inspected Ashlie's flat and discovered a well-established fire. Thick smoke prevented them from entering and extracting Ashlie. 999 was called at 02 .13 hrs. Staff actions led to a delay of between 43 and 28 minutes in calling 999. Firefighters attended the premises within 5 minutes of the 999 call. The fire spread throughout the building and was eventually brought under control at 05.30. Ashlie was found deceased in the hallway of her flat, in front of the front door. A fire investigation found that the lock on Ashlie's door was operated by a 4 digit key­ pad both internally and externally. Despite the presence of a fail-safe, activated by the fire alarm which would have deactivated these locks. The presence of a key-pad on an exit was described as both unusual and dangerous. Fire safety procedures, policies and risk assessments in place at the unit were found to be unfit for purpose. A London fire brigade fire safety audit of the premises on 3rd October 2017 found that staff training and fire risk assessments were suitable and sufficient. The audit was determined to have been flawed CORONE~SCONCERNS 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 MATTERS OF CONCERN are as follows.
1. The operator of the premises failed to ensure that staff on duty were competent to carry out a fire evacuation . Despite reflection and remediation in policies, processes and training, multiple staff members who gave evidence to the inquest, remained unable to describe the proper action to take in the event of a fire alarm.
2. Fire Alarms in three units operated Sequence Care Group remain non-compliant with the 2013 British Standard Guidance, which recommends that they should have a link to an Alarm Receiving Centre ("ARC") which automatically contacts the emergency services when a fire alarm is activated.
3. The London Fire Brigade conducted fire safety audits at the premises which assessed the unit as displaying the highest standard of fire safety compliance. These findinqs were found to be entirely inconqruent with procedures, equipment and staff training in place before and at the time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 but they remain incomplete.
4. 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.
5. No clear guidance exists regarding the fitting of digital key-pad locks on doors in specialist housing.
6. Insufficient emphasis is placed upon recommendations contained within British Standards regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation.

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Report details

Reference
2022-0123
Date of report
26 April 2022
Coroner
Graeme Irvine
Coroner area
East London

Responses identified

Responses identified 4 of 4
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Jun 2022 (estimated).

Sent to

British Standards Institution
London Fire Brigade
National Fire Chiefs’ Council
Sequence Care Group

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