Christopher Butler

Dear Mr Clark RECEIVED Re: Regulation 28 Further to Fatal House Fire on 5 Sept 2014 involving Christopher John Butler of] land Inquest at Oxford Coroners Court on 21 January 2014 Thank you for your letter of 24 February 2015, written under Regulation 28 of The Coroners (investigations) Regulations 2013, concerning the inquest into the death of Mr Christopher John Butler who died tragically in the fire at on the 5 September 2014. Through your offices, may take this opportunity to express my sincere condolences to the family of Mr Butler: Following the receipt of your letter Oxfordshire County Council Fire and Rescue Service (OCCFRS) has undertaken a comprehensive review of the circumstances relating to this case_ We have taken this opportunity to further challenge how we identify, manage and deal with risk in the community We are also reviewing how to further improve our processes concerning investigating and fully understanding the circumstances to a future tragic incident: We consider that this approach wiil enable further information to support all investigations into the cause of the fire and also the wider causation that lead to these fatal events_ have considered the recommendation within your letter and offer the following response: can confirm that the circumstances relating to this case are under review; the review and our suggested future approach is using the Health and Safety HSG65 model of Plan, Do; Check and Act to ensure that the organisation improves its ability to identify and manage risk within the local community: have asked my Home and Community Safety Team to review the partnership arrangements in place across all stakeholders that came into contact with Mr Butler and identify if any concerns around risk were known and flagged to relevant stakeholders This will ensure future INVESTORS 35 IN PEOPLE Lu E edar Your good

intelligence concerning 'at risk' groups r individuals is shared earlier and in a more structured fashion We are also making improvements and reviewing our approach to incidents of this type to ensure that a critical review of our risk management is carried out earlier in order to inform any internal or external agency investigation or Coroner's Hearing: This new approach will be initiated for all significant "persons reported" (where a life is considered to be in the property) incidents so we can learn from a wider number f incidents which had the potential to lead to a fire fatality. This will enable us to identify the risk factors beyond those that we currently scrutinise and share this with the wider fire sector regionally and nationally. The outcome of the fire investigation in this specific case identified that the direct cause of the was attributed to an overheated cable caused by a sharp ninety degree bend in the wire probably formed during the installation stage. This could be replicated and present in many other internal wiring situations both locally and nationally: We will shortly be publishing and Providing a case study concerning this specific incident to the National Inspection Council for Electrical Installation Contracting (NICEIC) and the Electrical Safety Council to enable them to use it in the education of electricians around the country. have also asked our OCCFRS Home and Community Safety Team to inform and educate residents in the local area and as a result the following activities are being undertaken: We have identified a number of properties that were broadly similar in age and design and we wrote to these residents highlighting this fatal incident and have provided them with some additional preventative information We are reviewing the property information to determine who the house builder was and whether there been any local or national trends of fires with this organisation and will take further action as appropriate to our findings We have utilised our close links with Oxfordshire County Councils Social and Community Services in order to identify any specific vulnerable residents within this targeted area in order to provide further personal assistance to them We are also working with Adults and Social Services to review our Near Miss and Fatal Incident Review process in order to ensure our future approach is comprehensive and deliver internal reflective learning and offer best practice within the organisation and to the wider fire sector We are also working with Electrical Safety First in order to provide these residents with a comprehensive home electrical safety booklet plus we are signposting them to recognised electricians via the OCC Trading Standards 'Trust a Trader' list if needed some further expert advice We have identified a number of other local information avenues, for example Parish newsletters and residents groups to communicate safety advice and specifically some electrical fire safety advice We have released a general electrical fire safety press release and updated our public websites to raise the awareness and target home electrical testing including the safety benefits and importance of modern fuse box designs. As fire and rescue services, we continually learn each other following tragic and unusual incidents such as this and we will share the circumstances of the cause of this fire and the subsequent actions with 51 fire and rescue services via the Chief Fire Officers Association. 2 fire have will they fire from

attach a copy of the letter that we have sent to the residents in Kidlington and a copy of the Electrical Safety First booklet am grateful for your recommendations and can assure you of Oxfordshire County Council Fire and Rescue Service's continued commitment to ensuring that the safety of the community within Oxfordshire is our top priority. do hope the actions and measures we have taken above provide reassurance and directly address the issues raised in your Regulation 28 letter. Should you wish for any clarification concerning our course of action; please do not hesitate to contact me at the above address: