Frazer Livesey

Coroners Court: The Old Fire Station Kendal 
Coroner’s  Regulation 28 Letter     
Impact’s Response  

We note the matters of concern raised in the Coroners Regulation 28 Letter. We have 
carried out a full review of our approach to fire precaution and evacuation. This response 
has been prepared in conjunction with 
 of Total Fire Services Ltd and Rowena 
Jackson, independent Health and Safety Consultant1. It is broken down into 3 key sections 

1.  What we currently do,  
2.  Our review of the incident and  
3.  What we intend to do following the Inquest verdict. 

It is perhaps worth stating at the beginning that Impact’s buildings and Fire Safety 
procedures worked to legislation, good practice and as designed. Fire alarms, etc., worked 
as they should and the means of exit worked as they should. There is a question over the 
tightness of fire seals around the designated exit door from the flat but this is normal in 
the event of a fire, albeit making the door more difficult to open. The Coroner’s question 
seems to be entirely around whether anything can and should be done to the windows in 
this flat and other flats to make it easier for an occupant to escape in case of fire 

Mike Muir 
Chief Executive 
Impact Housing 
February 2017 

1   Darren Baird DMS, MIFireE, MIFSM Total Fire Services Ltd 
     Rowena Jackson BSc (Hons) CMIOSH 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
 
 1.  WHAT WE CURRENTLY DO 

In both our general needs and our supported housing, we work to 4 linked considerations, 
which we will explore in detail, below: 

i. 
ii. 
iii. 
iv. 

What does a risk based approach mean? 
What are the design requirements and other constraints of the building? 
What are the characteristics and needs of the tenants in each building? 
What are the management arrangements in place to support those tenants? 

i How impact operates a risk based approach  
For all of our properties, in respect of fire and other risks and in respect of our various 
systems and management practices, we consider 3 variables: the use of the building, the 
needs of the tenants that we are housing and the sort and level of support that we 
provide. Our approach to a modern house with a general needs tenant is very different 
from an old block of flats with vulnerable tenants and a package of support.  In all cases, 
around Fire Safety, we rely on our own systems and training backed up by specialist fire 
safety advice and inspection from Total Fire Services Ltd. (Fire Risk Assessments, 
consultancy and Reports) and other health and safety advice from 
(Health & Safety Consultant).  

We operate to current Building Regulations and all other relevant Legislation, Guidance 
and Good Practice. In respect of schemes like the Old Fire Station, specifically,  

  we give guidance to tenants on what to do to prevent fire and what to do if it 

breaks out 

  we carry out regular Fire Drills (ie full practice evacuations) 
  we have a current Fire Risk Assessment 
  we regularly inspect tenants’ flats 
  we work to the Police Secure by Design  

We understand that the Fire Officer’s statement to the Inquest confirmed that Impact had 
done everything correctly within current fire safety legislation. The designated fire exit 
route (the flat entrance door) worked as intended. The fire was contained within the flat. 
The other residents were evacuated without injury.  

ii The Design and other Constraints of this Building  
For the last 30 years, Building Regulations have specified certain windows in residential 
properties to be “escape windows” which are designed to be easily opened from the 
inside in an emergency. Typically, escape windows will have one full opening light, that 
opens sideways, that is easy to open and, where lockable, is easy to unlock from the inside 
in an emergency. Such windows are required where there is no other satisfactory means 
of escape- typically, bedrooms at the end of a corridor on the first floor of a family house. 
Blocks of flats and 3 storey houses will usually have a good means of escape through 
protected exit routes. Escape windows are not considered as a secondary means of escape 
above the first storey (4.5m) for safety reasons.   

 
 
 
 
 
 
 
 
 
 iii The Tenants of this Building  
As the Fire Officer indicated at the Inquest, escape windows are not recommended in a 
property such as the Old Fire Station, where the designated means of escape is adequate. 
Indeed, in all of our schemes for vulnerable tenants, for security reasons and personal 
safety, we  normally ensure that individuals cannot exit from windows.  
We would in general discourage tenants from opening a restrictor window that has been 
placed there for their personal safety and security.  

iv Management Support at this Building  
We have a risk based approach to our relationship with our tenants. In schemes such as 
the Old Fire Station, we have an Evacuation policy and have practice fire drills for 
residents. We also have specific clauses in our Tenancy Agreement to cover the current 
circumstances which caused the fire: 

23.1 You must not store in your home or communal areas, quantities of 
inflammable explosive or potentially dangerous materials or gases other than those 
which may be reasonably required for domestic use; nor store any petrol driven 
vehicle or appliance within the dwelling or in communal areas, other than 
designated parking areas or leave bicycles anywhere that they could cause an 
obstruction or fire hazard.  
23.2 You must not hoard items in your home if that may be a fire or health risk or 
prevent access to your property.  

We design buildings for specific uses, we house specific groups of tenants with specific 
needs and we provide competent staffing support to meet those needs. We have a 
number of projects for young people with varying combinations of building design, 
tenants’ needs and tenant support. For our young people, we provide a safe and secure 
environment, we provide a balance of support and independence, so we assist them to 
learn life skills, engage with specialist agencies to move them into training or employment 
and, in due course, assist them to move on to independent living. 

Thus, we allow our tenants to have visitors, we have tenancy rules, we have room 
inspections, but we do not have curfews, we do not have 24 hour on site staffing support. 
This is a particular model that we have developed successfully over many years that 
balances support and independence.  

 
 
 
 
 2.  OUR REVIEW OF THE INCIDENT FOLLOWING THE INQUEST 

Following review of the evidence supplied at the Inquest, discussions with our own staff, 
with the tenant concerned, with the Fire Investigation Officer who attended the scene, 
with our own Fire and Health & Safety consultants (see above) and from looking again at 
our records, including CCTV coverage, and at our procedures, we had come to the view 
that the incident was a tragic accident involving two young men who were carrying out an 
activity that was not allowed and which entailed significant risk to themselves and others. 
Impact followed all of the relevant legislation and good practice and its own internal 
procedures. However, in our current, further, consideration of the Incident, we have 
considered our existing position, viz 

1.  The fire safety arrangements and procedures in place worked as they were 

designed2 

2.  There was nothing further that a reasonable landlord could be expected within 

existing good practice to have done to foresee and prevent 

3.  The incident and sequence of events were of a unique and unusual nature (the 
consequences of a rapid flash over from ignited petrol vapours) that residential 
properties cannot reasonably be foreseen and designed to protect against 
4.  Changing the opening arrangement of those windows might have made a 

significant difference to the outcome. However, subject to what alternative 
arrangements we made, it might also have created a number of other problems 
and risks (say, delay in the tenant exiting, or distraction from, the correct exit 
route). The same issues would apply to our other properties more generally and 
the redesign of their windows 

Impact Housing has been operating as a housing charity for 42 years. Throughout that 
time, with a very good safety track record, we have provided family and general needs 
housing and supported housing to many thousands of Cumbrian households. One of our 
key specialisms has been in the provision of housing and support to vulnerable people, 
including young people from the age of 16 upwards. We hope that, through constantly 
reviewing our procedures and learning from incidents such as this, we constantly refine 
our approach to those very important roles. 

In this document, we set out some of the proposals that we will implement and the 
learning that we are now putting in place following the Incident. 

2 The compelling evidence that has led to us to this view is the CCTV footage “OFS Fire Lobby CCTV 
Footage”, a copy of which was presented to the Inquest. It shows our tenant leaving the flat and, 
indeed, returning to it. It shows that the smoke and blast were contained within the flat and the 
designated exit route had worked as designed.. 

 
 
 
                                                        
 3.  WHAT WE INTEND TO DO FOLLOWING THE INQUEST 

1.  Our Tenancy and Licence Agreements cover such forbidden activities. We will 

ensure that younger residents in particular are more regularly reminded of the risks 
of carrying out forbidden activities in our buildings, with further explanation as to 
why these are forbidden activities 

2.  Whilst the likelihood of this incident happening again is extremely low, we will 

redouble our efforts to remind our tenants of the risks from forbidden appliances 

3.  We have a number of slightly different housing and support arrangements, for 
which we have slightly differing procedures (eg. fully supported schemes, low 
support schemes, newly designed schemes, schemes where there is a change of 
use, properties where there is a change of tenant). Whilst there is nothing that we 
will do significantly differently in the Old Fire Station (other than works to the 
windows; see below), there is a potential weakness where a situation changes- in 
particular where the use of the building changes (say, a more vulnerable tenant) 
and where we are considering changing a building component (say, replacing an 
existing window). We will bring in new procedures to ensure that any new risks 
introduced as a result of these changes of circumstance are reduced so far as is 
reasonably practicable 

4.  Whilst the fire evacuation arrangements worked as planned, we will reiterate to all 
of our staff the need to periodically remind our tenants of the procedures in place 
for their specific circumstances 

5.  With our 2 lead consultants, we will carry out a further, high level, review of our 

higher risk properties to see if there is any further learning 

6.  In this property and across our wider stock, we will look again at the arrangements 

for window design, as set out in greater detail, below 

  
 
 
 
 
 
 
 Impact Approach to Window Design and Window Restrictors 
The main reason for fitting restrictors is to reduce the risk of falling from height, 
although we would also generally fit restrictors to ground floor windows as both an 
additional security measure and/or for outward opening windows to reduce the risk of a 
window being opened and hitting a passer-by.  The type of restrictor fitted is generally 
the hook type which is fitted to the opening sash and hooks over a pin fitted to the frame 
or a restrictor as an integral part of the hinge.  
In the case of the Old Fire Station, windows consist of small panes, with an opening lower 
light which has a hinge half way down both sides allowing it to pivot from vertical to 
horizontal on this central point; this means that, when open, the bottom third (roughly) 
of the window opening is fully accessible. See below for details of current restrictors. 

We have several problems to address in deciding our general course of action: 

1.  Whilst it is relatively easy to fit a restrictor which is easy for the tenant to 

override, it is more difficult for a restrictor to be overridden by a visitor who does 
not know the property and who is in distress.  

2.  Not all properties can have their restrictors removed (eg on upper floors where 
the risk from a fall would be high or where Building Regulations do not allow it) 

3.  Not all windows can be easily exited because of their design (eg top opening 

lights or where there are small fixed panes in a listed building) 

4.  Not all tenants could be allowed to have windows that are easy to exit (eg those 

with dementia or otherwise impaired judgement) 

5.  We do not want to do anything to confuse the tenant in what is the designated 

and prfered exit route in case of an emergency 
6.  The cost of replacement can be prohibitely high 

In this particular flat (Old Fire Station, ground floor), our proposal is as follows: 

a.  There are simple “cable restrictors” on the windows (see diagram). We will 

remove them. This will allow exit, albeit with some slight difficulty.  
A work order has been issued and the works will be completed by Friday 17 
February 

More generally, we have now considered the Coroner’s recommendations and, below, set 
out the approach that we will be taking across the whole of our stock (including The Old 
Fire Station). This approach builds on the risk based approach that we have across all of 
our responsibilities. 

New Development 
Properties 
Newbuild schemes that have 
not yet reached Building 

Controls 
Building Regulation approval 
is in all cases required for the 

Action 
Windows installed in schemes 
from now on (see definition)  

 
 
 
 
 
 
 
 
 
 
 
 
 Contract Signed Stage 
(c30 new flats/houses  per 
annum) 

works, and therefore the 
windows installed would have 
to comply and be approved by 
Building Control (and also on 
new build the third party 
warranty provided, such as 
LABC, Premier Guarantee etc) 
also up to relatively recently 
the most schemes would be 
Govt funded and have to meet 
the “Housing Quality 
Standards”. All of these 
requirements put differing 
constraints on the exact 
nature of any windows and 
opening mechanisms. 

Properties bought from a 
private developer 
(6 units in 2017 and typically 
per annum) 

Refurbished or remodelled 
properties that have not yet 
reached Building Contract 
Signed Stage or where Work 
Orders have not yet been 
issued 
(22 units in 2017 and typically 
per annum) 

Restrictors are generally not 
fitted. We have little control 
over the specific design of 
these properties as they are 
bought “off the shelf” on a one-
off basis. 
If Building Control permission 
is required or properties are 
listed,  then windows and 
restrictors will meet 
regulatory requirements. 

will normally be UPVC 
outward opening side hung 
casement window, with easy 
clean hinges (to enable the 
window to be cleaned from 
the inside) with lockable 
handle and a restrictor which 
can be easily  overridden in an 
embergency. In specific cases 
(eg general needs ground 
floor properties) it may be 
possible to design without a 
restrictor  

Planning restrictions or 
specific building limitations, 
mean that a variety of 
windows will continue to be 
installed, such as top hung 
windows, timber, tilt and turn. 
We will design these windows 
without restrictors on the 
ground floor and on upper 
floors with restrictors that are 
easy to override in an 
emergency. Within those same 
restrictions, we will design the 
windows so that they can be 
exited in an emergency 

As above, subject to 
constraints set out here 

New windows, as above, from 
now on 

From now on, in such schemes, 
where we are not replacing 
windows, existing windows 
with restrictors without an 
override will be adapted or 
replaced to achieve as near as 
possible the approach set out 
above 

Existing Properties 
Properties  
Residential properties with staff on site. 
Vulnerable tenants, different building 

Action 
All properties to be surveyed by end March 
2017 to identify styles of windows and window 

 
 
 
 
 
 
 
 
 
 types and sizes.  
(64 properties, with varying number of 
flats or bedspaces) 

Properties as they become void. General 
needs tenants. 
(250 – 300 per annum) 
All other general needs properties. 
2,300 properties 

locks fitted. Works to remove fixed restrictors 
and replace with restrictors which can be over-
ridden will  commence in April 2017 and 
complete by end-March 2018.. Within that 
timescale, the order will be based on the level 
of risk to residents, phasing and availability of 
funding. 
As “Refurbished or remodelled properties “ 
above 

To be assessed through general stock condition 
surveys, repairs or maintenance. As properties 
become vacant,  I.e. (“Properties as they 
become void”) they will be treated as for  
“Refurbished or remodelled properties “above.  
We have a 5yr rolling programme of inspection 
of all properties and we will include the 
removal or replacement of restrictors in those 
properties as they come up for inspection. 

Exceptions 

1.  On inspection, if there are any properties where none of the above actions can be 
considered to ground floor windows, we will consider, on a case by case basis, 
provision of a break-glass hammer to be placed alongside that window. In such 
properties, if they exist, we will also conside on an individual property-by-property 
risk basis, a similar provision on first floor windows. This is not a satisfactory 
solution, because of the risk from broken glass and our inability to have assurance 
that the hammer remains in place. 

2.  We will continue to restrict ease of window exit for all properties with tenants in 

upper floor flats with dementia or otherwise impaired judgement, where the risk 
to them of trying to jump from a window would be too great