Sean Ennis

Andrew Walker 
Senior Coroner 
North London Coroners Court 
29 Wood Street 
Barnet 
EN5 4BE  

Dear Mr Walker 

Date: 14th April 2022 
Ref: Assist 

Barnet Assist’s response to the Coroner’s Report dated 21st February 2022 

Further to the Regulation 28 Report to Prevent Future Deaths dated 21st February 2022, 
concerning the death of Sean Ennis on 19th April 2021, please find below Barnet Assist’s 
response. 

Assist (“Barnet Assist”) is the trading name of Barnet Homes Limited’s telecare service, based in 
the London Borough of Barnet, but providing telecare operator and mobile response services to 
over 20 Registered Social Landlords, including Network Homes, the landlord of property where the 
death occurred. 

1)  Whilst the property at Knighleas Court is not within the borough of Barnet, nor owned or 
managed by Barnet Homes, we undertake to co-operate with any actions carried out as 
part of a fire risk assessment that directly affect the service provided by Barnet Homes. 

2)  Barnet Homes undertakes to engage and co-operate with any review of telecare legislation 

and regulations and work to and, where possible, exceed any minimum standards 
introduced as a result. 

3)  Barnet Homes undertakes to engage and co-operate with the Telecare Services 

Association (TSA) in exploring sustainable funding sources to enable all vulnerable 
residents in need of telecare to be provided with a full system. 

4)  Barnet Assist is a member of the TSA, and we are actively considering whether to apply to 
be accredited as part of an ongoing wider service review which is due to conclude later this 
year. Barnet Assist already meets or exceeds the TSA targets for both call answering and 
mobile response. 

5)  Barnet Homes manages properties on behalf of the London Borough of Barnet (LBB) with 

whom the tenants have their tenancy agreements. Barnet Homes will pursue the 
recommendation with LBB to incorporate the requirement for Sheltered Housing tenants to 
have a home fire safety visit by the local fire and rescue service. Barnet Homes already has 
a memorandum of understanding with the London Fire Brigade (LFB), which includes a 
programme of staff training in identifying vulnerable residents and fire safety visits for its 
residents. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6)  Barnet Homes currently carries out Person Centred Risk Assessments (PCRAs) and 

prepares Personal Emergency Evacuation Plans (PEEPs) where appropriate, where the 
need is identified by Sheltered Housing Officers. Anonymised and colour coded versions of 
these are stored in the red Premises Information Boxes (PIBs) outside each Sheltered 
Housing scheme and are currently working closely with the LFB to provide the information 
to them electronically. Barnet Homes will now carry out PCRAs on all its Sheltered Housing 
tenants: 

i.  on new tenant move-in, and 
ii.  reviewed no less than every 12 months, 
iii.  or when circumstances for the individual change  

The target date for completion of any missing PCRAs in Sheltered Housing is Monday 16th 
May 2022. 

7)  All Barnet Homes’ managed Sheltered Housing schemes have a category L1 fire alarm 
system designed for the protection of life, which have automatic detectors installed 
throughout all areas of the buildings (including roof spaces and voids) with the aim of 
providing the earliest possible warning. These systems are linked to an external monitoring 
system monitored by Barnet Assist and a 24-hour backup monitoring station from a 
secondary provider, Custodian. 

I trust that this is satisfactory, but please let me know if you have any questions or if you require 
any further information. 

Yours sincerely 

Head of Care and Support

HM Coroner Andrew Walker  
North London Coroners Court  

Sent via email to: admin.beh@hmc-northlondon.co.uk  

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Fax: 03000 616171 

www.cqc.org.uk 

25 April 2022 

Dear HM Coroner Andrew Walker  

Regulation 28 Report following the inquest into the death of Mr Sean Ennis 

We write further to the Regulation 28 report dated 21 February 2022, that you made 
following the inquest into the death of Mr Sean Ennis after a fire at Knightleas Court.  
The report was sent on to us by the London Fire Brigade and whilst we were not 
asked to respond to the report directly, the Care Quality Commission (CQC) has 
carefully considered the matters raised in your Regulation 28 report.  

At CQC, we make sure that health and care services in England provide people with 
safe, effective and high-quality care. We monitor, inspect and rate the quality of care 
of providers and highlight to them where they need to make any improvements in 
their standards of care. If they do not meet the legal requirements, known as 
Fundamental Standards, we take action to make sure they improve. 

CQC is responsible for the regulation of providers and managers where they are 
carrying on a regulated activity as defined in the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014. The setting where this incident occurred, 
Knightleas Court, is a sheltered housing service in Brent and is not registered with 
CQC as it is not providing any regulated activity. In addition, we have spoken with 
the London Borough of Brent adult social care team and have been advised that Mr 
Sean Ennis was not in receipt of any care service and as such we cannot inspect or 
take any further regulatory action in this case.  

However, we do note your comments about the use of Person-Centred Fire Risk 
Assessments and recognise this as an important issue. CQC inspectors have been 
trained in fire safety in supported housing through their induction training, and this 
training is guided by the National Fire Chiefs Council’s very comprehensive guidance 
on Fire Safety in Specialised Housing. We are currently working closely with the 
National Fire Chief’s Council on how we can promote the use of Person-Centred Fire 
Risk Assessments further with both CQC registered providers and landlords of 
sheltered housing.  

20220419 Reg 28 response to NL Coroner re Mr SE v1.0 v1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We kindly thank you for your report. If you have any questions please do not hesitate 
to contact me with any questions.   

Yours sincerely 

Head of Inspection, ASC London 

20220419 Reg 28 response to NL Coroner re Mr SE v1.0 v1

HM Senior Coroner  for the Northern District of 
Greater London Andrew Walker 
North London Coroners Court 
29 Wood Street 
Barnet 
EN5 4BE 

11 April 2022 

Inquest Touching the Death of Sean Ennis 
Response to Regulation 28 Report to Prevent Future Deaths 

Dear Sir 

We write on behalf of Network Homes (“NH”), to whom you sent a Regulation 28 Report dated 21 

February 2022 in relation to the Inquest held before you on 16 November 2021(“the Regulation 28 

Report”). The below letter constitutes NH’s response under paragraph 7(2) of Schedule 5 of the 

Coroners and Justice Act 2009 and under regulation 29 of the Coroners (Investigations) Regulations 

2013, and discharges NH’s duties under those provisions. 

1. NH would like to start by assuring both you and the public of their firm commitment to doing

everything it can to help ensure the safety of those residents in its premises. NH has always had

this at the heart of what it does, and as such there is a constant and ongoing system of review

and improvement of all fire safety systems and preventative measures across all of their

premises.

2. NH’s fire safety management and systems go above and beyond that required by the law, and

above the general standards across the industry, and in fact reflect best practice. NH’s fire safety

team work proactively in conjunction with their Primary Fire Authority, London Fire Brigade

(“LFB”), in order to promote fire safety across all premises.

3.

In relation to the fire at Knightleas Court, we note the finding of LFB’s Fire Investigation Team

Report (dated 26 April 2021) that:

 
 
 
 Page 

2 

“11.2 Fire safety regulation considerations at time of fire:  … [fire safety legislation] does not 

apply, fire did not travel outside of the flat of origin. No issues noted by Senior Fire Safety 

Officer.” 

General Response to the “Matters of Concern” 

4. 

It is noted that the “Matters of Concern” raised in the Regulation 28 Report are lifted wholesale 

and verbatim from LFB’s letter to you of 26 October 2021. Indeed, Matter of Concern 2 still starts 

with “The London Fire Brigade believe…”. 

5.  Following the Inquest, you invited submissions and evidence with respect to prevention of future 

deaths. In response, NH provided a 38-paragraph witness statement from 

, NH’s Fire 

Safety Contracts Manager, which responded to many of the points that now form the “Matters of 

Concern”. No reference is made to 

 statement in the Regulation 28 Report, and so it is, 

unfortunately, not entirely clear if that statement has been considered before the Regulation 28 

Report has issued.  

6. 

If it had in fact been considered, and you have made an informed decision that there are still 

further points that NH needs to answer, then it is unfortunate that those remaining concerns have 

not been specified – regrettably, without knowing exactly the basis upon which you may consider 

these matters to be outstanding, it is difficult for NH to frame its response as helpfully as it might 

otherwise have been able to do.  

7.  Additionally, it is noted that in that letter, LFB’s recommendations were directed not just to NH 

and the other two recipients of the Regulation 28 Report, but also to The Home Office (Fire Policy 

team), the Care Quality Commission, All London Local Authorities, and the National Fire Chiefs 

Council. This would appear to be due to a recognition on the part of LFB that many of the 

“Matters of Concern” it raised make recommendations that go well beyond, and are in some cases 

incompatible with, current fire safety legislation and guidance. Such recommendations would 

therefore require new legislation or policy change, rather than action by individual dutyholders. 

8.  The effect of now directing these “Matters of Concern” to the dutyholders only, and not those 

responsible for policy and guidance, is that any reader could be misled into thinking that HM 

Coroners’ criticisms amount to failures on the part of NH (and potentially the other two 

recipients) to comply with the current fire safety legal framework and contemporary standards. 

That is simply not the case. With respect to the issues raised, NH is fully compliant with the 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 Page 

3 

Regulatory Reform (Fire Safety) Order 2005, and in many cases goes well above and beyond those 

requirements in order to achieve best practice and to protect residents as far as it is able to. 

The Nature of Residence Within Knightleas Court (and other similar premises) 

9.  Knightleas Court is sheltered accommodation consisting of 67 self-contained, independent living 

flats. It is accommodation for elder residents with the benefit of communal facilities, but retaining 

independent living for residents. Individual flats are the private homes of those residents. 

10.  No care facilities are provided. Knightleas Court, and other sheltered accommodation, is very 

different to facilities providing care services, such as care homes. 

11.  If residents do develop care or support needs, those residents would be sign-posted or referred 

to other voluntary or statutory agencies where their needs can be met by those providers. NH 

does not provide care services. 

12.  As explained in more detail below, NH completes regular reviews of the Person-Centred Risk 

Assessments and document and assesses any vulnerabilities that may result in resident’s ability 

to respond to a fire. 

The Legal Fire Safety Framework 

13.  Fire safety of premises in England and Wales is regulated by the Regulatory Reform (Fire Safety) 

Order 2005 (“RRO”). RRO imposes obligations on the Responsible Person for particular parts of 

premises, and empowers fire authorities (such as LFB) to enforce those provisions. In addition, 

guidance on the obligations under, and enforcement of, RRO is provided by Chief Fire Officers 

Association (“CFOA”) and National Fire Chiefs Council (“NFCC”). 

14.  Under Article 6(1)(a) RRO, none of the obligations under RRO (save in relation to Prohibition 

Notices, which is irrelevant here) apply to domestic premises. This means that, although the 

common parts of sheltered housing buildings (corridors, stairways etc) are covered by RRO, the 

individual flats themselves are not. 

15.  Therefore, NH does not owe duties under RRO with respect to individual flats, or with respect to 

any activity taking place within them. Inter alia, there is no duty under article 8 RRO to take 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

4 

general fire precautions in relation to individual homes, and there is no duty under Article 9 RRO 

to conduct a Fire Risk Assessment in relation to individual flats. 

16.  The logic of RRO in this regard is clear – those individual flats are the private homes of the 

residents, an Englishman’s home is his castle, and so the building owner has no right (or 

obligation) to infringe upon the private homes of its tenants. 

17.  That this is the case is recognised clearly in the relevant guidance documents: 

a. 

 Appendix 1 of the CFOA “Enforcers Guidance”:  

“Sheltered Housing 

Accommodation may be provided as either flats or as separate houses.  … These 

premises are treated as private dwellings.  The Order does not apply to the dwellings 

but may apply to any common facilities and office accommodation where this is 

provided on site. 

… 

Implications of the Order as it applies to Flats 

… The Order imposes obligations on the responsible person to take general fire 

precautions in respect of the common parts of a block of flats (but not the individual 

flats themselves). … The common parts of blocks of flats (e.g. halls, stairs, landings, 

lifts etc) are subject to the Order but individual flats fall outside its scope” 

b.  Section 30 of the NFCC’s “Fire Safety in Specialised Housing” guidance: 

“30.1  The Regulatory Reform (Fire Safety) 

Order 2005 (the ‘FSO’) does not apply to individual private dwellings and units of 

accommodation, other than in respect of measures installed within that 

accommodation as part of the building-wide fire strategy to protect residents of 

other accommodation.  However, the FSO does apply to common parts.” 

c. 

In relation to the Knightleas fire itself, by LFB’s Fire Investigation Team Report (dated 26 

April 2021): 

“11.2 Fire safety regulation considerations at time of fire:  … RRO does not apply, fire 

did not travel outside of the flat of origin. No issues noted by Senior Fire Safety 

Officer.” 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 Page 

5 

18.  Under RRO, LFB are given extensive powers and mechanisms by which they may enforce 

requirements under that legislation. The reason that LFB have not been able to enforce the 

“Matters of Concern” themselves via those powers is because those issues do not relate to legal 

requirements under RRO – LFB has no legal power to enforce them, because they are not the law. 

Person-Centred Risk Assessments 

19.  Notwithstanding the legal position above, NH in fact seeks to implement best practice and the 

non-mandatory suggestions from the NFCC’s “Fire Safety in Specialised Housing” guidance with 

respect to its housing – including, in particular, with respect to Person-Centred Risk Assessments 

(“PCRAs”). 

20.  PCRAs are completely distinct to the legally-mandated Fire Safety Risk Assessments required 

under Article 9 RRO. Fire Safety Risk Assessments deal with the fire safety of the building, 

whereas PCRAs attempt to identify and assess specific factors in relation to individual residents. 

21.  Part D of the NFCC’s “Fire Safety in Specialised Housing” guidance explains: 

“The person-centred approach, based on a person-centred fire risk assessment, relates to 

the safety of residents who are at high risk from fire in their own accommodation; as such, 

this risk assessment and measures identified by it are outside the scope of the Fire Safety 

Order, but are strongly recommended as good practice. … 

… A person-centred fire risk assessment should consider the propensity of the resident to 

contribute to the likelihood of fire or fire development, the mental capacity of the resident to 

recognise and respond appropriately to fire alarm signals or signs of fire, and the ability 

of the resident to escape in the event of fire.” 

22.  The NFCC’s “Fire Safety in Specialised Housing” guidance also contains an exemplar PCRA within 

its Appendix 4. 

23.  With respect to PCRAs, you have already received the following evidence in the witness statement 

of 

. NH can do little more to explain the position with respect to PCRAs than repeat 

her evidence again: 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

6 

21. PCRA were completed by meetings in person with all tenants at Knightleas Court 

in 2018.  

22. Under the NFCC Guidance for specialist housing it does not detail the frequency 

with which they should be reviewed. NH have adopted the standard template for 

PCRAs contained in that guidance. 

23. However, NH policy was/is to review all its PCRAs on a 1,2-, and 3-year cycle; 

unless a new vulnerability or change to existing vulnerability is identified by the 

scheme manager. 

24. High risk is reviewed annually and lower risk every 2 years, low risk every 3 years. 

25. Mr Ennis’ PCRA was completed at a meeting within the property (like all PCRAs). 

The document shows that at the time there was no reason to suspect there was a 

risk of careless disposal of cigarettes nor that NH should update the PCRA sooner 

than intended, in line with NH’s policy. 

26. I do not believe that it is possible or practical to assess the number of cigarettes 

or where they are smoked within each tenant’s flat. These factors are likely to vary 

throughout a day and from day to day. The NFCC Guidance does not suggest that 

as part of the PCRA process an assessment be made in relation to the number of 

cigarettes smoked and location that takes place. 

27. In Mr Ennis case, whilst we accept the PCRA said it would be reviewed in 2019 and 

was not, due to his assessed low risk status, he was not in fact due a review until 

2021.  

28. NH accepts the PCRA programme was slightly behind schedule due to the 

pandemic and inability to hold face to face meetings with tenants in their flats. A 

proper assessment of the risk can only be carried out by meeting in the flat with 

its tenant. 

29. I can confirm that all tenants at Knightleas Court and at the other NH schemes 

have since this fire had their PCRA reviewed. Those identified as vulnerable and 

who may require assistance evacuating, are recorded and information is held in 

the premises information box. 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

7 

30. As was heard in evidence there are measures in place should residents need 

assistance. There are pull cords in each room which when activated connect the 

flat to the Barnet Assist call centre so assistance is available if staff are not on site. 

31. It must be accepted that if a tenant is overcome by smoke they would not be able 

to activate the pull cord so that is why there is automatic smoke detection in place 

and which worked. 

32. NH do install fire suppression systems (sprinklers) and other aids if risks of a fire 

or ability to evacuate are identified. At this time there is no requirement on NH to 

retro fit a sprinkler system throughout Knightleas Court. 

33. NH work collaboratively with the local authorities to ensure residents are in 

appropriate housing. If it is deemed that a resident can no longer live 

independently the local authority are responsible for rehousing residents into care 

or supported housing accommodation. NH does not have any care homes. 

Specific Responses to Matters of Concern 1-7 

34.  The below respond to each of your individual Matters of Concern so far as NH is able to respond 

to them. 

Matter of Concern 1: 

35.  NH has carried out a comprehensive Fire Risk Assessment for all of the areas of premises for 

which it is the Responsible Person. Fire Risk Assessments are reviewed every year at this site, or 

sooner if there is a significant change in the premises. 

36.  When improvements or additional requirements are identified in a Fire Risk Assessment those 

actions will be given a target date based on risk and the extent of the work required. NH aims to 

complete all work before the target date, often doing so well before the target date. The target 

dates of works form part of the ongoing Fire Risk Assessment process – as part of that process, in 

conjunction with the Fire Risk Assessor, some actions are re-profiled and amended target dates 

are given.  

Matter of Concern 2: 

37.  This is not an issue for NH to address. 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

8 

Matter of Concern 3: 

38.  This is not an issue for NH to address. 

Matter of Concern 4: 

39.  This is not an issue for NH to address. 

Matter of Concern 5: 

40.  Whilst NH recognises that the provision of advice from LFB to residents could be of assistance to 

those residents with respect to fire safety within their flats, and it is happy to LFB to provide such 

advice, NH does not consider that it is appropriate to make this a mandatory condition of tenancy 

within its sheltered housing. 

41.  The changing of terms within tenancy agreements are of significant undertaking that requires 

consideration of a huge number of issues and requires consultation with, and the agreement of, 

residents. This is particularly so given that the suggestion at Matter of Concern 5 falls outwith the 

legal obligations of RRO, and is not even a recommendation within the relevant NFCC guidance. 

42.  Parliament chose, by enacting s6 Fire and Rescue Services Act 2004, to impose upon fire and 

rescue services the duty for making arrangements for the provision of advice to residents on fire 

prevention and means of escape. It is not appropriate for LFB or a Coroner to seek to circumvent 

this and to place the obligation on a third party such as NH. LFB is of course welcome to provide 

advice to residents, so as to comply with its obligation under s6 Fire and Rescue Services Act 

2004, on a voluntary basis, and NH are happy to consider any practical requests from LFB about 

how it might reasonably assist in this regard. 

Matter of Concern 6: 

43.  This matter of concern contains a number of errors/inaccuracies. The reference to what should or 

should not have been done in the past is outside of the proper scope of any PFD report. 

Additionally, as covered above, PCRAs are not required by law, and so it also incorrect to say that 

PCRAs “should” have been done. 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

9 

44.  As explained above, NH, as a responsible landlord, voluntarily carries out PCRAs so as to achieve 

best practice and as high a standard of safety for its residents as can reasonably be achieved. 

45.  PCRAs are reviewed regularly, in accordance with the recommendations in section 39 of the 

NFCC’s “Fire Safety in Specialised Housing” guidance. They will be reviewed if there is a significant 

change in circumstances, and otherwise they are periodically reviewed at either one, two or three 

year intervals dependent upon the risk/needs level of the individual to whom the PCRA relates. A 

one-size-fits all approach is not appropriate. No reference is made to a maximum review period 

of 12 months within the NFCC guidance. It is therefore not correct to say that “PCRAs should be 

reviewed on a regular basis, not less than every 12 months…” – there is no formal guidance that 

recommends such an approach. 

46.  During the Covid-19 pandemic, NH’s programme of reviewing PCRAs was delayed. In-person 

visits, a necessary step involved in conducting PCRAs, were not conducted so as to protect the 

residents from the significant risks from Covid – many of the residents were those most at risk 

from covid. NH conducted additional telephone-based welfare checks with residents during this 

so it could continue to provide the best level of support it could, given the difficult circumstances. 

47.  Following the lifting/relaxing of restrictions, all PCRAs have been reviewed. PCRAs for Knightleas 

Court have been provided to LFB, and no issues with these have been raised. 

Matter of Concern 7: 

48.  NH’s fire prevention, detection and response systems are adequate and appropriate, based on 

applicable law and guidance. If LFB considers that this is not the case in any specific regard, then 

it is more than welcome to liaise directly with NH to voice its concerns so that these can be 

addressed. 

Summary 

49.  Network Homes takes fire safety extremely seriously and is committed to complying with all its 

statutory obligations under the RRO and all other fire safety guidance. It is in a committed 

partnership with the LFB to ensure its buildings are managed effectively.  

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 Page 

10 

50.  The fire safety arrangements at Knightleas Court, and similar premises, are appropriate to the 

nature of those premises as sheltered accommodation which supports independent living (but 

which does not provide care services). 

51.  In relation to the fire on 19 April 2021, the fire safety systems behaved, and the fire safety 

equipment activated, as expected. Those systems were maintained in line with RRO and industry 

guidance. The fire was successfully contained within the flat of origin, which demonstrates the 

ability of the property to perform as expected in the event of a fire. 

The above letter constitutes NH’s response under paragraph 7(2) of Schedule 5 of the Coroners and 

Justice Act 2009 and under Regulation 29 of the Coroners (Investigations) Regulations 2013, and 

discharges NH’s duties under those provisions. 

NH would be grateful if, before publishing this response or making it more widely available, both you 

and the Chief Coroner would consider redacting the names of any individuals from the above 

response letter. In our experience this is common practice, but we include the request herein 

expressly, pursuant to Regulation 29(8) Coroners (Investigations) Regulations 2013. 

Yours faithfully 

Weightmans LLP 

Weightmans LLP 
On behalf of Network Homes