Paul Hutchinson: Prevention of future deaths report

[REDCATED], Interim Chief Executive, Local Government Association
[REDACTED], Minister for Housing Communities and Local Government
[REDCATED], Chair, National Fire Chiefs Council
[REDCATED], Interim Chief Executive, Care Quality Commission

I am Richard Furniss, HM Assistant Coroner for West London.  

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

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 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

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.

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.   

In my opinion action should be taken to prevent future deaths and I believe you, the four organisations listed above to whom this report is directed, have the power to take such  action. 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 June 2026. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
 
[REDACTED]
[REDACTED] Chief Executive, Housing 21

I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of  interest. You may make representations to me, the coroner, at the time of your response,  about the release or the publication of your response by the Chief Coroner. 

20 April 2026
 
[REDACTED]
Signature
Richard Furniss HM Assistant Coroner for West London