Prevention of Future Deaths reports · 2022

Saima Usman

Regulation 28 report to prevent future deaths, reference 2022-0108, written 8 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Apr 2022
Reference2022-0108
DeceasedSaima Usman
CoronerProfessor Fiona Wilcox
Coroner areaLondon Inner (West)
CategoryOther related deaths · Alcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Chief Executive  
London Borough of Wandsworth. 

1  CORONER 

I am Prof essor Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West 
London 

2  CORONER’S LEGAL POWERS 

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. 

3 

INVESTIGATION and INQUEST 

On the 22nd March 2022, evidence was heard touching the death of Saima Usman. Ms 
Usman had been found deceased at her home following a fire. She was 44 years o ld at 
the time of her death. 

Medical Cause of Death 

1 (a) Mixed opioid toxicity 

11 

How, when, where the deceased came by her death: 

Ms Usman was found deceased and partially burned ay the LFB at her home address at 
around 11pm on 8th July 2021. The f ire did not contribute to her death. The source of the 
f ire was likely to be from her burned clothing, either from a lighter or cooker, but her drug 
toxicity caused her collapse and prevented her f rom extinguishing the fire. Thre were no 
suspicious circumstances and no evidence of self harm. 

Conclusion of the Coroner as to the death 

accidental drug related death 

4  Circumstances of the death. 

Extensive evidence was taken and accepted by the court. In summary: 

Ms Usman lived in flat belonging to a private landlord. There was no smoke detection 
system within the property.  

 
 
 Whilst in this case this would have been unlikely to have prevented the death, in other 
cases smoke alarms certainly allow earlier detection of fires and the prevention of 
deaths, and the limitation of spread of fire to adjacent properties as emergency services 
are called earlier. 

Evidence from the Fire Brigade investigator was that Local Authorities currently have no 
legal powers to enforce smoke or carbon monoxide (CO) detectors to be installed in 
privately rented property. Had the property been rented from the LA, they could have 
ensured that such safety systems would have been in place. 

Other LAs have registered landlord schemes that ensure that in order to be registered 
smoke and CO detectors must be installed. 

5  Matters of Concern 

That those living in privately rented accommodation within the London Borough of 
Wandsworth are at greater risk of death from exposure to fire or CO, as it does not 
currently have registered landlord scheme through which in order to be registered 
smoke and CO detectors would have to be installed. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organisation] have the power to take such action. It is for each addressee 
to respond to matters relevant to them. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report. 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. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons : 

, 

102, New Park Road, 
London. 
SW2 4LN. 

Station Officer Fire Investigation Team G/W, 
Dowgate Fire Station, 
2nd Floor, 
94-95 Upper Thames Street, 
London. EC4R 3UE. 

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 
f orm. 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.  

9 

8th April 2022 

Professor Fiona J Wilcox 

HM Senior Coroner Inner West London 

Westminster Coroner’s Court 
65, Horseferry Road 
London 
SW1P 2ED   

Inner West London Coroner’s Court, 
33, Tachbrook Street, 
London. 
SW1V 2JR 

.

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