Source · Prevention of Future Deaths
Paul Hutchinson
Ref: 2026-0223
Coroner: Richard Furniss
Area: West London
0 responses identified · 4 indexed addressees
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AI-generated concerns summaryThe coroner noted that fire safety regulations do not mandate personal emergency evacuation plans or standardised staff training for individual flats in residential care. Additionally, Fire Risk Assessments may not adequately account for the specific risks posed by vulnerable residents.
56-day deadline
16 Jun 2026
stated in the report
Responses identified
0 of 4
Coroner's concerns
The coroner noted that fire safety regulations do not mandate personal emergency evacuation plans or standardised staff training for individual flats in residential care. Additionally, Fire Risk Assessments may not adequately account for the specific risks posed by vulnerable residents.
View full coroner's concerns
1. 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. 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.
2. 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.
3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming ‘any group of persons identified…as being especially at risk’ (see article 9(7)(b) of the 2005 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 concern is that Fire Risk Assessments do not take this into account.
2. 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.
3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more generally may not contemplate vulnerable residents as forming ‘any group of persons identified…as being especially at risk’ (see article 9(7)(b) of the 2005 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 concern is that Fire Risk Assessments do not take this into account.
Report sections
Investigation and inquest
On 23 January 2025 I commenced an investigation into the death of Paul HUTCHINSON. The investigation concluded at the end of the inquest on 20 April 2026. The conclusion of the inquest was Accidental Death
The medical cause of death was
1a Burns
The medical cause of death was
1a Burns
Circumstances of the death
The Deceased died of burns in a fire in his Extra Care Sheltered Accommodation (‘ECSA’) on 21 January 2025.
The building comprised 36 one-and two-bedroomed flats. The Deceased lived in a one-bedroom flat. He had suffered a stroke in 2016 which caused him to have limited mobility and speech, incontinence and cognitive difficulties. ECSA means that he lived independently in self-contained accommodation but with managed on-site care and support on a 24-hour basis.
In August 2024, a Person Centred Fire Risk Assessment (‘PCFRA’) determined the risk as ‘high’. There were multiple burn marks on clothing , carpet and furninshings as a result of the Deceased smoking, but no adequate control measures or mitigating measures were recorded or taken, and there was no action to notify a local Fire Officer.
The Deceased set himself alight by smoking. His smoke detector activated at 1435 hours on 21 January 2025, but was silenced by a member of staff, as were multiple other detectors. The first call to London Fire Brigade was 8 minutes after 1435 and the manager of the accommodation did not contact LFB until 1450 hours.
The inquest heard evidence and submissions from London Fire Brigade
The building comprised 36 one-and two-bedroomed flats. The Deceased lived in a one-bedroom flat. He had suffered a stroke in 2016 which caused him to have limited mobility and speech, incontinence and cognitive difficulties. ECSA means that he lived independently in self-contained accommodation but with managed on-site care and support on a 24-hour basis.
In August 2024, a Person Centred Fire Risk Assessment (‘PCFRA’) determined the risk as ‘high’. There were multiple burn marks on clothing , carpet and furninshings as a result of the Deceased smoking, but no adequate control measures or mitigating measures were recorded or taken, and there was no action to notify a local Fire Officer.
The Deceased set himself alight by smoking. His smoke detector activated at 1435 hours on 21 January 2025, but was silenced by a member of staff, as were multiple other detectors. The first call to London Fire Brigade was 8 minutes after 1435 and the manager of the accommodation did not contact LFB until 1450 hours.
The inquest heard evidence and submissions from London Fire Brigade
Copies sent to
[REDACTED] [REDACTED] Chief Executive, Housing 21
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Report details
- Reference
- 2026-0223
- Coroner
- Richard Furniss
- Coroner area
- West London
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Jun 2026 (stated in the report).
Sent to
- Care Quality Commission
- Local Government Association
- Minister for Housing Communities and Local Government
- National Fire Chiefs Council