Caroline Oliver

Dear Mr Graham Thank you for your Regulation 28 Report dated 14 April 2026 (“the PFD”), following the conclusion of your inquest into the death of Caroline Olive Oliver (“Caroline”), who died on 10 December 2025 at the age of 88. Before addressing the specific concerns raised, Sanctuary wishes to express its sincere condolences to Caroline’s family. Caroline’s death is a matter of deep sadness, and Sanctuary has treated the circumstances surrounding it with the utmost seriousness. The PFD is addressed to Sanctuary Housing Association. Sanctuary Housing Association is a Registered Society as defined in section 1 of the Co-Operative and Community Benefit Societies Act 2014 (Registration Number 19059R) (“Sanctuary”). Sanctuary is a not-for-profit Registered Social Landlord with the Regulator of Social Housing (Registration number LO247). Sanctuary notes, as recorded by the Coroner, that it is not possible to determine whether the presence of the boxes caused Caroline’s fall, and no such finding was made. The Coroner’s conclusion was a short form conclusion of accidental death, and that Caroline died following complications arising after a fractured neck of femur sustained in a fall at her home. Your specific concerns, relating to Sanctuary, are recorded in the PFD at Box 5. Sanctuary understands your main concerns are: (a) A lack of clear controls or time limits. (b) Potential hazard created by prolonged storage of household items. (c) Ongoing risk to other tenants. I want to assure you that Sanctuary takes the safety of our residents seriously, and I will outline the controls Sanctuary has in place and how we are continuously improving how we work.

IN PEOPLE Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Registered office: Sanctuary House, Chamber Court, Castle Street, Worcester, WR1 3ZQ Registered as a provider of social housing with the Regulator of Social Housing No. L0247 Registered Society No. 19059R Printed on recycled paper Highly Confidential

[Page 2] Sanctuary 2 Sanctuary’s response to concerns raised in the PFD: 1 Background
1.1 Caroline’s Tenure
1.1.1 Caroline lived at 20 Park Close, Yarnton, Oxfordshire, 0X5 1QQ (“the Property”). Caroline’s tenancy commenced on 17 November 2003. The Property is a bungalow and is in a close of similar properties.
1.1.2 The Property is a social housing property that is let as a general needs home. General needs customers live independently in self-contained homes with no additional support or care services provided by Sanctuary. Within the general needs context, Sanctuary delivers the service of a social landlord in line with its policies, procedures and processes, utilising contractors to assist with the delivery of some services we deliver. Our policies aim to strike the right balance between Sanctuary’s role as a landlord and allowing its residents to have independent quiet enjoyment of their homes.
1.2 Sanctuary's Energy Efficiency Retrofit Programme 1
1.2.1 Sanctuary’s Corporate Strategy 2026-2030 includes a commitment to delivering homes that are fit for the future through continued investment in its housing stock. This includes Sanctuary’s Sustainability Retrofit Programme (“the Programme”), which supports customer safety, environmental sustainability and compliance with the Government's energy efficiency targets for socially rented homes. The Programme is part of Sanctuary’s wider goal to seek to make a positive difference in society, the environment and ultimately a positive impact on our customers, in line with our Decarbonisation and Net-Zero 2 Strategy (the Net Zero Strategy) .
1.2.2 The Programme is managed by Sanctuary’s Property Services Directorate within the Energy Team. In support of its Net Zero Strategy over the previous two financial years Sanctuary has seen over 5,400 homes achieve EPC C across multiple programmes.
1.2.3 The Property was included within the Programme for the installation of solar panels and loft insulation.
1.2.4 Contractors were appointed through a public competitive tender process. The works to Caroline’s property were allocated to Correct Contract Services (“CCS”), one of three retrofit contractors appointed by Sanctuary and responsible for approximately 25 per cent of works under the Programme. 1Sanctuary’s Corporate Strategy 2026-30 <https://www.sanctuarv.co.uk/about-sanctuary/corporate-strateqv> 2Sanctuary's Decarbonisation and Net Zero Strategy < https://www.sanctuary.co.uk/sustainabilitv/environment/decarbonisation-and- net-zero-strateqy> Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 3] Sanctuary 3
1.2.5 The Programme is substantial in scale. In 2025/2026, Sanctuary’s Energy Team completed works in 1,717 homes, with approximately 5,151 jobs completed over the previous 12 months. CCS completed approximately 1,500 jobs for Sanctuary in 2024/2025, around 95 per cent of which involved loft works, all requiring asbestos testing. Of those jobs, only nine identified asbestos.
1.2.6 Save for the circumstances of this case, no other significant issues of this nature have arisen in connection with the performance of the Works. 2 Your Concerns
2.1 I will now respond to each of your concerns, providing you with additional information about Sanctuary and our contractor CCS to assure you we take the safety of our customers seriously, with a commitment to continuous improvement in our approach, policies and processes.
2.2 Concern 1: Lack of clear controls or time limits
2.2.1 Sanctuary manages contractor risk through a robust framework including contractual controls, our supplier code of conduct and our policy and procedure framework. In connection to the Retrofit Works at the Property the controls in place are outlined below. Sanctuary expects its contractors to proactively protect the health and safety of customers, employees and others via risk assessment. In each individual case we would expect this to include considering any risk posed by the storage of items, tools or equipment throughout the lifecycle of a job. We would expect any risk and risk mitigation to be explained to our customers and where appropriate be escalated to Sanctuary for us to take additional actions necessary to mitigate the risk.
2.2.2 For the retrofit works, Sanctuary appointed CCS under a JCT contract. This required CCS to: (a) Treat residents respectfully, especially vulnerable people. (b) Communicate clearly with residents before and during works. (c) Keep health and safety documents up to date. (d) Ensure staff are properly trained and compliant with the law. (e) Promote a strong health and safety culture with proper training. 3
2.2.3 CCS also had to follow Sanctuary’s Supplier Code of Conduct , which requires: (a) Compliance with laws and standards. (b) Proper health and safety measures in place (including training, PPE, safe working). (c) Extra care and communication where works affect residents. 3Sanctuary’s Supplier Code of Conduct < https://www.sanctuary.co.uk/sites/default/files/2026-05/Supplier-Code-of-Conduct-2026 pdf> Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 4] Sanctuary 4
2.2.4 Sanctuary’s policy framework includes a range of policies and procedures to protect the health and safety of our customers. Those relevant to the Works are: (a) Sanctuary Vulnerable Customers - Group Policy and Procedure - outlines the approach Sanctuary take in working with vulnerable customers. This was approved in April 2024 and recognises the importance of understanding customers’ needs. As part of this, Sanctuary introduced an ongoing customer census, starting in early 2024, to support a drive for better information on our customers. (b) As part of Sanctuary’s health and safety policy framework, the Health and Safety Management of Contractors - Group Procedure provides guidance to ensure that Sanctuary’s teams take a proactive approach to the management of contractors engaged across the Group, including within the Property Services and Development teams. Applying the principles of that Procedure, the Energy Team established its own formal Contractors Management Process in 2024 to provide a clear framework for managing contractor relationships in line with health and safety requirements. This bespoke process sets out the relevant guidelines and procedures for team members, maintains an annual record of contractors, including key data and responsible officers, and provides for regular risk-based meetings with contractors. Those meetings follow a structured agenda covering: (i) safety performance and compliance; (ii) complaints and queries; (iii) contractor feedback and concerns; (iv) project updates; and (v) risk management.
2.2.5 In the delivery ofc. 5,151 Jobs, only one other job was noted as having extended storage of household items, without incident.
2.2.6 Sanctuary’s Construction Design and Management (CDM) Team, part of our wider health and safety team conducted CDM Site Safety inspections in the last twelve months to audit CCS whilst they were delivering the Programme. These took place on 2 July 2025, 23 September 2025, 21 January 2026, 1 April 2026, whereby CCS scored an average audit score of 92 per cent.
2.2.7 As part of further assurance which has taken place in the time since Caroline’s death, PWC audited the Energy Team’s Retrofit Programme in February 2026: (a) The review covered the wider programme management design and effectiveness, governance, roles, risk and issue management, escalation, and reporting within Sanctuary’s control environment. The focus of the review was not specifically about health and safety practices. Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 5] Sanctuary 5 (b) The audit found strong management arrangements, defined governance, accountability, and escalation processes, with effective oversight through multiple levels and regular reporting, supporting decisions and risk management. (c) One advisory was noted suggesting the documentation of a high-level, programme-wide escalation framework that sets out indicative escalation criteria or thresholds (for example, cost, delivery, compliance, health and safety). This would provide additional clarity and consistency within the Programme. The audit noted no control weaknesses or missed risks were found and there was no negative impact on delivery.
2.2.8 In consideration of this advisory Sanctuary’s Energy Team established a Risk Escalation Framework to provide a clear, programme-wide structure to identify, escalate and respond to risk issues and deviations within the Programme. This was across a range of criteria and thresholds including cost, delivery, compliance and health and safety. (a) Originally, under the Risk Escalation Framework health and safety would have covered risk to vulnerable residents in its escalation criteria, which would be escalated on a zero-tolerance basis with triggers for near misses or low level health and safety concerns (Tier 1 - Project Managers manage this level of risk), repeat occurrences and unresolved health and safety risk (Tier 2 - reportable to Head of Energy Efficiency) and any RIDDOR incident, unsafe practice with serious harm potential or contractor removal (Tier 3 - Reportable to Divisional Director). (b) As part of the ongoing learning, the Energy team are separating out customer vulnerability as its own escalation criteria as part of the ongoing process.
2.3 Concern 2 - Potential hazard created by prolonged storage of household items
2.3.1 Sanctuary expected the Works to be conducted with reasonable care and skill. CCS had a Designated Safeguarding Lead with a Level 3 Certification to support the delivery of the Programme. CCS followed a defined procedure to support vulnerable customers in delivery of the Programme.
2.3.2 CCS operates a vulnerability profiling guestionnaire, whereby Caroline was identified as an elderly resident. As a proactive contractor, CCS created a vulnerability flag, whereby it would flag every time someone attended the property that there was a vulnerability - 'elderly lady extra support required’. In addition, CCS conducted a risk assessment prior to the Works commencing at the Property. Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 6] Sanctuary 6
2.3.3 CCS provided assistance to customers who had other barriers which would prevent them benefiting for the works. In this instance this included supporting Caroline to remove the household items from her loft in order for the Works to be carried out to Property.
2.3.4 Sanctuary’s understanding of the series of events, based on our records and those provided by CCS were outlined in our statement previously provided to the Coroner.
2.3.5 Sanctuary has robust policies and procedures in place; however, we will utilise this opportunity to further strengthen the implementation of our policies and procedures, which will include: (a) Immediate Process Change - The Energy Team improved the process in delivery of the Programme so that any extended storage of items, here being storage of household items for longer than one day, has to be escalated to the Head of the Energy Efficiency Team who is able to monitor their presence. This process has now been implemented nationally to all energy staff and third-party supply chain partners. (b) Vulnerabilities - Customer Data is currently captured at tenancy commencement, through proactive and transactional tenancy visits through the lifetime of their tenancy, and direct notification from tenants or their families. Sanctuary is taking steps to further improve its vulnerability data by considering various data touchpoints and sources it holds to improve reporting to one central location. This will enable Sanctuary’s housing and property services operational teams, as well as our customer hub, to have: (i) access to the most recent data held on our customers circumstances and needs; and (ii) a clear central reporting process to amend customer details to reflect changes in their circumstances and needs. (c) Flagging system - Sanctuary operates a system of "Person Alerts", a formal process where vulnerability or risk has implications for safety, access, or communication needs. Steps are being taken to ensure that any identified vulnerability flags are consistently applied and that information is shared across teams and with contractors. (d) Introduction of new system - Sanctuary is currently conducting a project to implement a new Customer Experience system. The intention is for this to improve the identification and flagging of vulnerabilities and give customers greater opportunity to keep their information up to date through a self-service capability. Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 7] Sanctuary 7
2.4 Concern 3 - Ongoing risk to other tenants
2.4.1 The Coroner expressed concern that if similar circumstances were to arise in other properties, particularly those occupied by elderly, disabled, or mobility- restricted tenants, there is a risk of future deaths or serious injury arising from restricted movement or trip hazards.
2.4.2 As already stated, whilst there is no recorded evidence of any previous similar incidents occurring, Sanctuary takes this concern very seriously and is implementing a number of measures to add to its existing robust systems and procedures. Notwithstanding this, to summarise the immediate, medium- and long-term changes Sanctuary intends to make: (a) Those improvements noted in paragraph 2.2.8 above; (b) Those improvements noted in paragraph 2.3.5 above; (c) Training - (i) Mandatory and refresher training is completed relative to job role across Sanctuary's workforce. This includes the Vulnerable Customers Group Policy and Procedure, Safeguarding Group Policies and Procedures, Wellbeing and Crisis Guidance, Customer Vulnerabilities E-Learning, and Awaab's Law E- Learning. Quarterly Safeguarding Champions meetings are held with Area Managers from across areas of Sanctuary Group including Housing England, Housing Scotland, and Sanctuary Supported Living. In these meetings, guidance on safeguarding referrals is regularly covered and learning from case review is shared with customer facing colleagues. Housing Officers are tasked with conducting proactive visits to capture customer vulnerability data and complete property checks, prioritising our quieter tenancies where we have not had reason to access the home or had contact with the customer. (ii) Sanctuary will ensure that Senior Management Teams conduct a training refresher of the Group’s Vulnerable Customers Policy and Procedure as part of learning to ensure this is embedded across teams. (d) Contractors - we will circulate a reminder to our active suppliers to remind them of our Code of Conduct, our Vulnerably Customer Policy and confirming reporting routes for identifying customer vulnerabilities. 3 Conclusion
3.1 We can assure the Family and the Coroner, that as an organisation we take our responsibilities extremely seriously, and our focus and priorities are always directed towards the best interests of our customer. Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential

[Page 8] Sanctuary 8
3.2 Sanctuary has treated the circumstances surrounding Caroline’s death with the greatest seriousness. Whilst this was an isolated incident arising from an unusual combination of circumstances, Sanctuary has undertaken a thorough review of its policies, procedures, and processes and acted on identified areas for improvement as a matter of best practice. The actions set out above are designed to ensure that the concerns raised by the Coroner are addressed comprehensively and that the risk of a similar incident occurring in the future is minimised so far as reasonably practicable.
3.3 Sanctuary is committed to the safety and wellbeing of all its customers, including those who are elderly, disabled, or otherwise vulnerable, and will continue to monitor and review the implementation of the measures described in this letter.
3.4 In accordance with Regulation 28(2) of the Coroners (Investigations) Regulations 2013, Sanctuary does not object to this response, or a summary of it, being disclosed to the family of Mrs Oliver or being published by the Chief Coroner. Again, I would like to express my sincere condolences to Caroline’s family and loved ones at this difficult time. Our thoughts remain with them. If you require any further information, then please do not hesitate to contact us. YYoouurrss ffaaiitthh:: Group CChhiieeff EExecutive Printed on recycled paper Sanctuary is a trading name of Sanctuary Housing Association, an exempt charity Highly Confidential