Ashleigh Timms

F r o  m: 
T o: 
C c: 
S u bj e c t: 
D a t e: 
A t t a c h  m e n t s: 

C or o n er s 

R ef  1 0 8 5 7 8  F A  O   Mr   G Ir vi n e  P RI V A T E  A  N  D  C  O  N FI  D E  N TI A L 
1 5  J u n e  2 0 2 2  1 2: 0 2: 1 7 

D e ar  Sirs, 
Pl e as e f or  w ar d t h e  b el o  w t o   Mr  G Ir vi n e,  A cti n g  S e ni or  C or o n er 
D e ar  Sir 
F urt h er t o  o ur  e  m ail  of  5   M a y, I  a  m   writi n g t o  u p d at e  y o u  o n  B SI’s r es p o ns e t o  y o ur  R e g  2 8 
r e p ort. 
M e  m b ers  of  B SI’s  c o  m  mitt e e  F S H/ 1 2 -  Fir e  d et e cti o n  a n d  al ar  m s yst e  ms  h a v e  dis c uss e d  y o ur  R e g 
2 8 r e p ort. 
T h e  c o  m  mitt e e  e x p erts  b eli e v e t h e  c o  m  mitt e es   w hi c h s h o ul d  e x a  mi n e t h e iss u es   m or e  cl os el y 
ar e: 

a.   T e c h ni c al  c o  m  mitt e e  F S H/ 1 4 -  Fir e  pr e c a uti o ns i n  b uil di n gs.  T h e s c o p e  of t h e  c o  m  mitt e e is 

“t h e  d e v el o p  m e nt  of  N ati o n al st a n d ar ds f or fir e s af et y  pr e c a uti o ns i n r esi d e nti al  a n d 
c o  m  m er ci al  b uil di n gs, fir e ris k  ass ess  m e nt  a n d fir e ris k   m a n a g e  m e nt s yst e  ms. ” 

A  m o n g  ot h er st a n d ar ds,  F S H/ 1 4 is r es p o nsi bl e f or  B S  9 9 9 1  Fir e s af et y i n t h e  d esi g n,   m a n a g e  m e nt 
a n d  us e  of r esi d e nti al  b uil di n gs -  C o d e  of  pr a cti c e.  T h at st a n d ar d is  c urr e ntl y  b ei n g r e vis e d,  a n d is 
d u e t o  g o f or  p u bli c  c o ns ult ati o n  o n  2 1 J ul y  2 0 2 2. 

b.   S u b c o  m  mitt e e  F S H/ 1 2/ 1.  T h e s c o p e  of t h e  c o  m  mitt e e is:  “I nst all ati o n  a n d  S er vi ci n g - t h e 
d e v el o p  m e nt  a n d   m ai nt e n a n c e  of  Britis h  St a n d ar ds  a n d t h e  U K i n p ut i nt o  C E N/ T C 7 2, 
I S  O/ T C 2 1/ S C 3  a n d t h eir   W or ki n g  Gr o u ps i n t h e  ar e a  of  pl a n ni n g,  d esi g n, i nst all ati o n  a n d 
s er vi ci n g  of s yst e  ms ”. 

A  m o n g  ot h er st a n d ar ds,  F S H/ 1 2/ 1 is r es p o nsi bl e f or  B S  5 8 3 9- 1: 2 0 1 7  Fir e  d et e cti o n  a n d fir e  al ar  m 
s yst e  ms f or  b uil di n gs -  C o d e  of  pr a cti c e f or  d esi g n, i nst all ati o n,  c o  m  missi o ni n g  a n d   m ai nt e n a n c e 
of s yst e  ms i n  n o n- d o  m esti c  pr e  mis es,  a n d   B S  5 8 3 9- 6: 2 0 1 9 + A 1: 2 0 2 0  Fir e  d et e cti o n  a n d fir e  al ar  m 
s yst e  ms f or  b uil di n gs -  C o d e  of  pr a cti c e f or t h e  d esi g n, i nst all ati o n,  c o  m  missi o ni n g  a n d 
m ai nt e n a n c e  of fir e  d et e cti o n  a n d fir e  al ar  m s yst e  ms i n  d o  m esti c  pr e  mis es. 
F S H/ 1 2/ 1   m et  o n  1 0 J u n e,  a n d  h a v e i d e ntifi e d t h e f oll o  wi n g  as p e cts  of  B S  5 3 8 9- 1 t o  b e 
c o nsi d er e d  as  p art  of  a f ut ur e r e vi e  w,  a n d  als o t o  b e  c o nsi d er e d i n r es p e ct  of  B S  9 9 9 1  b y  F S H/ 1 4: 
1.   W h et h er  B S  5 8 3 9- 1 s h o ul d i n cl u d e  u n d er  us er r es p o nsi biliti es  a n i nf or  m ati v e  n ot e t h at 
t h e  us er   m a y   wis h t o r e q u est  a  c o  m pl et e r e vi e  w  of t h e  “ a d dr ess es ”  of fir e  d et e ct ors  at 
r e g ul ar i nt er v als, f or  e x a  m pl e,  5  y e ars. 

2.   W hil e  B S  5 8 3 9- 1  alr e a d y  d et ails  a  n e e d f or  us ers  of t h e st a n d ar d t o  c h e c k z o n es  a n d 

c o nfir  m z o n e  pl a ns, it is  pr o p os e d t h at  c o  m  m e nt ar y  b e  a d d e d t o  4 6. 2  a n d/ or  2 3. 1   m a ki n g 
t h e ris k t o lif e fr o  m  a l a c k  of  a z o n e  pl a n  v er y  cl e ar.  T h e t e xt  c o ul d  als o list t h e l a c k  of  a 
z o n e  pl a n  as  a   m aj or  n o n- c o nf or  mit y   O R t h e l a c k  of  a z o n e  pl a n i  m  m e di at el y r e n d eri n g t h e 
s yst e  m  n o n- c o  m pli a nt.  T his   m a y i n cl u d e t h e  a bs e n c e  of  a n  A R C. 

3.   R e g ar di n g  A R C  c o n n e cti o ns, t h e  c o  m  mitt e e  n ot e d,   m a n y  Fir e   &  R es c u e  S er vi c e ( F R S)  ar e 
o p er ati n g  a  nil-r es p o ns e  p oli c y t o  A F As ( A U T  O  M A TI C  FI R E  A L A R  Ms).  T h e st a n d ar d   m a y 
i n cl u d e  a r e c o  m  m e n d ati o n t h e  us er t o  d et er  mi n e   w h at t h e  p oli c y is f or t h e l o c al  F R S  a n d 
c o nfir  m   w h et h er t h e  pr e  mis es  ar e i n cl u d e d  or  e x e  m pt. 

4.   C urr e ntl y t h e st a n d ar d  all o  ws  v ari ati o ns t o  b e   m a d e  a n d t h e s yst e  m still  b ei n g  c o nsi d er e d 
c o  m pli a nt.  T h e  c o  m  mitt e e  h as  pr o p os e d t h e  cr e ati o n  of  a list  of  c ert ai n  v ari ati o ns t h at 
c a n n ot  b e  all o  w e d,  a n d t h at s yst e  m still  b e  c o nsi d er e d  c o  m pli a nt.  T h e  n e e d t o j ustif y t h e 

 
 
 
 
 
 
 
 v ari ati o n(s)   m a y  als o  b e i n cl u d e d i n t h e  cl a us e. 

5.   W h et h er  a n i nf or  m ati v e  n ot e  b e i n cl u d e d t h at st at es  a n  al ar  m  c a n n ot  b e r es et  u ntil t h e 

c a us e  of t h e  al ar  m is r es ol v e d.  H o  w e v er, it   w as  n ot e d  a n y  n e  w   w or di n g   w o ul d  b e  a d d e d t o 
cl a us es  p ert ai ni n g t o  us er  o p er ati o n r at h er t h a n  a n y  n e  w r e c o  m  m e n d ati o ns f or 
m a n uf a ct ur ers. 

6.   T h e  c o  m  mitt e e is  c o nsi d eri n g i n cl u di n g  a r e c o  m  m e n d ati o n t h at t h e  e v e nt l o g s h o ul d  b e 

l ar g er.  H o  w e v er, t h e y  n ot e d t h at  o n e iss u e is t h at  “ e v e nt ” is  v er y  br o a d.  As  p art  1 is  a  C o P, 
t h er e  ar e li  mits t o   w h at  c a n  b e r e c o  m  m e n d e d  a n d  a  E N  5 4  pr o d u ct st a n d ar d   m a y  b e 
b ett er  pl a c e d.  T h er e  ar e  als o t e c h ni c al li  mit ati o ns. It  h as  b e e n  pr o p os e d t h at t e xt  b e 
a d d e d t o  c o  m  m e nt ar y t h at  p oi nts  o ut t h at   m a xi  m u  m  n u  m b er  of r e c or d a bl e  e v e nts is  9 9 9 
b ut   m or e   m a y  b e  n e e d e d,  a n d t h o u g ht s h o ul d  b e  gi v e n t o  pr o vi di n g   m or e  c a p a cit y f or 
a d dr ess a bl e s yst e  ms. 

It   w as  als o  a gr e e d t h at  B S  5 8 3 9-6: 2 0 1 9 + A 1: 2 0 2 0  n e e ds t o  b e r e vi e  w e d  a g ai nst t h e  a b o v e list  as 
t h es e  c h a n g es   m a y  n e e d t o  b e   m a d e t h er e. 
It   w as s u g g est e d t h at  B SI   m a y  n e e d t o   writ e t o  or i nf or  m  all  Fir e  a n d  R es c u e  S er vi c es  a n d 
p ossi bl y t h e  C ar e   Q u alit y  C o  m  missi o n ( C  Q C) t o i nf or  m t h e  m  of t h e  c h a n g es t o t h e st a n d ar d t o 
e n c o ur a g e  att e n d a n c e t o  A F As  d uri n g t h e  d a yti  m e. It   w as f urt h er s u g g est e d t h at t h e f a  mil y  of 
t h e  d e c e as e d  b e i nf or  m e d  as t o t h e  pr o p os e d  c o urs e  of  a cti o n  b y t h e r el e v a nt 
a ut h orit y/ or g a niz ati o n. 
R e g ar di n g t h e   m att er  of  k e y l o c ks, it   w as  a gr e e d s u b c o  m  mitt e e  F S H/ 1 2/ 4   m a y  c o nsi d er it  as  p art 
of  a f ort h c o  mi n g  a  m e n d  m e nt t o  B S  7 2 7 3- 4. It   m a y  als o  b e  c o v er e d  as  p art  of t h e  o n g oi n g 
r e visi o n  of  B S  9 9 9 1  vi a t h e i n cl usi o n  of  a n i nf or  m ati v e  n ot e t o t h e  eff e ct t h at  “if  el e ctr o ni c 
l o c ki n g is  pr o vi d e d  o n fl at  e ntr a n c e  d o ors  of i n di vi d u al  u nits  of  a c c o  m  m o d ati o n it s h o ul d  n ot  b e 
n e c ess ar y  or  n e e d e d t o i nst all  a  c o d e t o  e xist t h e fl at.   M e a ns  of  el e ctri c l o c ki n g s h o ul d  b e si  m pl e 
a n d  e as y t o  us e ( e g  a si  m pl e l e v er  h a n dl e). It is  als o i  m p ort a nt t h at r esi d e nts  u n d erst a n d  h o  w t o 
us e t h e  el e ctr o ni c l o c k. ” 
Fi n all y, it   w as  als o s u g g est e d t h at  B S  9 9 9 1  c o ul d s a y t h at  “ c o nsi d er ati o n s h o ul d  b e  gi v e n f or  A R C 
c o n n e cti o n i n  c ert ai n s u p p ort e d  h o usi n g ”  a n d f urt h er  g ui d a n c e  c a n  b e f o u n d i n  B S  5 8 3 9 -1. 
E a c h  of t h os e  p oi nts   will  b e  c o nsi d er e d  b y t h e r es p o nsi bl e  c o  m  mitt e e(s)  a n d   w e   will   writ e  a g ai n 
t o  u p d at e  pr o gr ess i n  d u e  c o urs e. 

Y o urs si n c er el y, 

 B A/ L L B (  H o n s)
H e a d  of  St a n d ar d s   G o v er n a n c e 

B SI,  3 8 9  C hi s  wi c k   Hi g h  R o a d,  L o n d o n,   W 4  4 A L,   U K

W e  s u p p ort t h e   U  N  S u st ai n a bl e   D e v el o p  m e nt   G o al s,  s o  pl e a s e  c o n si d er t h e  e n vir o n  m e nt  b ef or e  pri nti n g t hi s
e  m ail 
T h e  Briti s h  St a n d ar d s I n stit uti o n i s  a   m e  m b er  of  B SI   Gr o u p  a n d i s i n c or p or at e d i n  E n gl a n d  u n d er  R o y al  C h art er. It s  pri n ci p al  a d dr e s s i s  3 8 9
C hi s  wi c k   Hi g h  R o a d,  L o n d o n,   W 4  4 A L,   U nit e d  Ki n g d o  m

Your ref 

Our ref 

By email:

FAO HM Senior Coroner Graeme Irvine 
East London Coroners Court 
127 Ripple Road 
Barking 
IG11 7PB 

25 Fenchurch Avenue 
London 
EC3M 5AD 
United Kingdom 

DX 766 London City 

Direct Dial

16 June 2022 

Dear Sir, 

PREVENTION OF FUTURE DEATHS REPORT FOLLOWING THE INQUEST INTO THE DEATH OF 
MS ASHLIE TIMMS 

We  write  further  to  the  conclusion  of  the  inquest  into the  death  of  Ms.  Ashlie  Timms,  and 
the subsequent circulation of a Prevention of Future Deaths report, dated 26 April 2022, by 
HM Senior Coroner, Graeme Irvine (“the Report”). 

The Chief Operating Officer (and Acting Chief Executive Officer) of Sequence Care, Robert 
Dalrymple,  provided  two  statements  to  the  Inquest  on  behalf  of  the  organisation,  dated  7 
April  2022  (“First  Statement”)  and  11  April  2022  (“Second  Statement”).  These  statements 
outlined the remedial measures taken by Sequence Care since Ms. Timms’ death. 

Sequence  Care  as  an  organisation  is  determined  to  learn  all  the  lessons  it  can  from  the 
recently  concluded  Inquest  proceedings.  Sequence  Care  has  reviewed  the  contents  of  the 
Report and can update HM Senior Coroner on the following concerns. 

1.  The operator of the premises failed to ensure that staff on duty were competent to 
carry out a fire evacuation. Despite reflection and remediation in policies, processes 
and  training,  multiple  staff  members  who  gave  evidence  to  the  inquest  remained 
unable to describe the proper action to take in the event of a fire alarm. 

Kennedys is a trading name of Kennedys Law LLP. 
Kennedys Law LLP is a limited liability partnership registered in England and Wales (with registered number OC353214). 

Kennedys  offices,  associations  and  cooperations:  Argentina,  Australia,  Belgium,  Bermuda,  Bolivia,  Brazil,  Canada,  Chile,  China,  Colombia, 
Denmark,  Dominican  Republic,  Ecuador,  England  and  Wales,  France,  Guatemala,  Hong  Kong,  India,  Ireland,  Israel,  Italy,  Mexico,  New  Zealand, 
Northern  Ireland,  Norway,  Oman,  Pakistan,  Panama,  Peru,  Poland,  Portugal,  Puerto  Rico,  Scotland,  Singapore,  Spain,  Sweden,  Thailand,  Turkey, 
United Arab Emirates, United States of America. 

A list of Partners is available for inspection at our registered office at 25 Fenchurch Avenue, London EC3M 5AD. Kennedys Law LLP is authorised and 
regulated by the Solicitors Regulation Authority.  We use the word ‘Partner’ to refer to a member of Kennedys Law LLP, or an employee or consultant who 
is a lawyer with equivalent standing and qualifications. 

 
 
 
   
 
 
 
 
 
   
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 Steps were already being  taken  by  Sequence  Care to  address the Coroner’s concerns in 
this regard prior to the conclusion of the Inquest, as detailed in paragraphs 26 to 28 of 
Mr 

First Statement. 

In  light  of  the  Report,  Sequence  Care  can  now  provide  the  following  additional 
information to HM Senior Coroner in respect of each of these paragraphs as follows: 

26. Face to face fire safety training  is  now provided to staff.  This  training  is  provided 
annually  by  Pinnacle  and  is  delivered  at  each  premises.  The  training  covers,  amongst 
other things, evacuation routes and procedures,  fire drills and fire safety measures.  A 
copy of the training handbook provided to staff as part of that training is attached. 

The  face  to  face  fire  safety  training  provided  by  Pinnacle  is  specifically  fire  warden 
training. By training all its permanent staff to this level, Sequence Care aims to ensure 
that there will always be a fire warden trained member of staff on duty at any one time. 

Sequence  Care  continues  to  provide  e-learning  to  all  permanent  staff  via  an  external 
third party (Care Skills Academy). However this is limited to an employee’s induction to 
the company and  is supplementary to specific face to face  induction training delivered 
 First Statement). 
at each home (see below in respect of paragraph 27 of Mr 

The face to face fire warden training is provided to all employees annually via Pinnacle, 
and any new joiners will be added on to the next available session  to supplement their 
e-learning. 

Further training sessions are also being carried out to ensure that any remaining staff are 
provided with outstanding training (see below). 

27.  Specific  induction  training,  tailored  to  each  of  Sequence  Care’s  premises,  is  also 
provided  to  the  permanent  and  agency  staff  assigned  to  work  there.  This  training  is 
delivered to staff by either the registered manager or one of the deputy managers. The 
training ensures staff are familiar with and have read the following: fire safety policy, 
accidents  and  incidents  procedure,  EMG  Response  Plan  and  support  plans/risk 
assessments/PEEPs  for  service  users  at  that  premises.  Completion  of  this  training  is 
confirmed  in  the  permanent  and  agency  staff  checklists  attached…Staff  refresher 
training is also provided annually. 

Sequence  Care  provided  HM  Senior  Coroner  with  copies  of  the  induction  checklists  for 
the  training  of  both  permanent  and  agency  staff.  The  provision  of  annual  fire  warden 
training (see above) aims to ensure that there will always be a fully trained permanent 
member of staff on duty at any given time. 

28. In addition, a competency assessment is carried out on an annual basis by either the 
registered manager or deputy manager (who are also to be trained by SOCOTEC in how 
to carry out this assessment) in the form of question and answer sessions, on which staff 

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 are  assessed.  This  ensures  management  monitoring  of  staff  training.  A  copy  of  the 
competency assessment checklist is attached at Exhibit RD/18. 

Face to face fire safety competency checks take place at individual homes on an annual 
basis.  The  competency  checklist  questions  were  revised  upon  the  conclusion  of  the 
Inquest.  The  updated  checklist  was  attached  as  the  above  referenced  exhibit  to  Mr 
First Statement, with the additional questions highlighted in red. Staff have 
been  re-assessed  against  the  revised  competency  checklist  following  the  conclusion  of 
the Inquest. 

Please  refer  to  the  enclosed  spreadsheet  which  records  the  completion  of  the 
competency  assessment  training  –  and  all  outstanding  training  - by  staff  members. 
Sequence  Care  has  arranged  additional  sessions  to  address  the  training  in  outstanding 
areas. 

2.  Fire  alarms  in  three  units  operated  by  Sequence  Care  Group  remain  non-compliant 
with the 2013 British Standard Guidance, which recommends that they should have 
a  link  to  an  Alarm  Receiving  Centre  (“ARC”)  which  automatically  contacts  the 
emergency services when a fire alarm is activated. 

As outlined in Mr 
First Statement, Sequence Care had already taken steps to 
ensure that the fire alarms in all but three of its homes were linked to an Alarm Receiving 
Centre (“ARC”). 

The Second Statement confirmed that, at that time, there were three homes within the 
Group  which  did  not  have  fire  alarm  systems  linked  with  an  ARC  as  recommended  in 
British  Standards  BS  5839-1.  Whilst  the  three  homes  did  not  adhere  to  the  guidance 
provided by the British Standards, it is not correct to say that they were non-compliant. 

Sequence Care has now arranged for the fire alarm systems at these homes to be updated 
so that they are compatible and for an ARC link to be installed. 

Details of the current status of these three homes are as follows: 

i. 

ii. 

iii. 

 – works completed and system (including 

ARC) activated on 20 May 2022; 

  –  works  due  to  be 
completed on 24 June 2022, the delay being due to the implementing team being 
absent due to Covid-19; 

  –  works  due  to  be 
completed on 24 June 2022, the delay being due to the implementing team being 
absent due to Covid-19. 

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 Yours faithfully 

4 of 4

London Fire Commissioner 

Her Majesty’s Coroner Mr Graeme Irvine 
Walthamstow Coroner’s Court 
Queens Road 
Walthamstow E17 8QP 

Dear Mr Irvine, 

London Fire Brigade Headquarters 
3rd Floor, 169 Union Street  London  SE1 0LL 

The London Fire Commissioner is the 
fire and rescue authority for London 

Date: 20 June 2022 

REGULATION 28 PREVENTION OF FUTURE DEATH REPORT (1) REF: 108578 

I am writing in response to your report dated 26 April 2022 (under the above reference) concerning 
the death of Ashlie Clare Liana TIMMS, which was initially sent to Deputy Assistant Commissioner 
Stephen Norman who gave evidence into the inquest. 

In your report you noted six areas of concern which were: 

1.  The operator of the premises failed to ensure that staff on duty were competent to carry out 
a fire evacuation. Despite reflection and remediation in policies, processes and training 
multiple staff members who gave evidence to the inquest, remained unable to describe the 
proper action to take in the event of a fire alarm. 

2.  Fire alarms in three units operated Sequence Care Group remain non-compliant with the 

2013 British Standard guidance, which recommends that they should have a link to an Alarm 
Receiving Centre (“ARC”) which automatically contacts the emergency services when a fire 
alarm is activated. 

3.  The London Fire Brigade conducted fire safety audits at the premises which assessed the unit 
as displaying the highest standard of fire safety compliance. These findings were found to be 
entirely incongruent with procedures, equipment and staff training in place before and at the 
time of the fire. The London Fire Brigade have reviewed and changed processes since 2018 
but they remain incomplete. 

4.  No clear and practical guidance exists on how specialist housing operators should manage 

the use of high-risk electrical devices such as portable electric fan heaters. 

5.  No clear guidance exists regarding the fitting of digital keypads on doors in specialist housing. 
Insufficient emphasis is placed upon recommendations contained within British Standards 
6. 
regarding automatic connections to ARCs in fire alarms fitted in specialist accommodation. 

It may be helpful to note at the outset, that for matters of concern numbered 4, 5 and 6, the 
Secretary of State for the Home Office is under a statutory duty in Article 50 of the Regulatory 
Reform (Fire Safety) Order 2005 (the FSO) to “…ensure that such guidance as he considers 
appropriate, is available to assist responsible persons in the discharge of their duties…”. Insofar as 
the matters of concern relate to parts of premises to which the FSO applies, it may be appropriate for 
these concerns to be drawn to the attention of Home Office ministers. My understanding is that the 
Home Office are currently engaged in a programme of refreshing national fire safety guidance 
documents that are used by both responsible persons and the authorities enforcing it.  

Similarly, the Secretary of State for the Department for Levelling Up, Housing and Communities has 
responsibility for the Housing, Health and Safety Rating System enforced by local authorities and 
which is applicable to the private domestic areas of many residential properties (where the FSO does 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 not apply). The Secretary of State has a duty to provide guidance on the assessment of hazards and 
enforcement against them in section 9 of the Housing Act 2004 and also provides other guidance for 
landlords and property-related professionals.  

There is a need for all guidance on these matters to be co-ordinated, clear and readily available 
across all reasonable sources. Consequently, I would suggest that your concerns in this regard are 
also raised directly with the relevant Secretaries of State. 

I have addressed each of the matters of concern below: 

1. 

The operator of the premises failed to ensure that staff on duty were competent to 
carry out a fire evacuation. Despite reflection and remediation in policies, processes 
and training multiple staff members who gave evidence to the inquest, remained 
unable to describe the proper action to take in the event of a fire alarm. 

This raises a concern that premises management is not compliant with duties under the FSO, in 
particular the duty in Article 15 concerning appropriate procedures to be followed in the event of 
serious and imminent danger to relevant persons. The FSO is a self-compliance regime with the duty 
for compliance placed firmly with the responsible person. As the London Fire Commissioner, I have a 
duty to enforce those regulations. In enforcing the FSO my officers must act in accordance with the 
requirements of the statutory Regulators Code. LFB Fire Safety Inspecting Officers plan to attend the 
premises shortly after the end of the 56 day reply period to conduct a regulatory audit under the 
FSO. This will consider whether there is compliance with the FSO including Article 15.  

2. 

Fire alarms in three units operated by Sequence Care Group remain non-compliant 
with the 2013 British Standard guidance, which recommends that they should have a 
link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency 
services when a fire alarm is activated. 

Regulators cannot directly enforce the recommendations of a British Standard unless it is cited as a 
required standard in relevant legislation or unless the arrangements actually in place can be shown 
to create a “risk gap” from the level expected by that standard. I understand the suggestion here was 
that the alarm did not include a link to an ARC because the premises had 24/7 staffing in place. LFB 
might consider this to be non-compliance with Article 13 of the FSO, although this would have to be 
considered in the light of the circumstances of an individual premises including the arrangements for 
staff training and testing of the arrangement. It would then be raised with the responsible person as 
part of any follow up to the regulatory audit.  

Making the recommendations of at least some British Standards directly enforceable is a matter that 
has been raised by other Coroners through regulation 28 reports with the relevant Secretaries of 
State, with support of the fire service. I would urge you to join them in to doing so.  

3. 

The London Fire Brigade conducted fire safety audits at the premises which assessed 
the unit as displaying the highest standard of fire safety compliance. These findings 
were found to be entirely incongruent with procedures, equipment and staff training in 
place before and at the time of the fire. The London Fire Brigade have reviewed and 
changed processes since 2018 but they remain incomplete. 

I would firstly refer you to the statement of DAC 
evidence to the inquest on 11 April 2022. 

 dated 8 April 2022 and his live 

In the year before the death of Ashleigh Timms, LFB had changed its policy on the vetting/review of 
fire safety regulatory audits by managers so as to include all audits of sleeping and vulnerable 

 sleeping accommodation regardless of the audit outcome. We have now undertaken a review of that 
element of policy and concluded that due to the ordering of paragraphs in the policy document a 
potential degree of ambiguity may have remained. That drafting has been addressed to place the 
matter beyond doubt and this has been promulgated to all staff working in the technical fire safety 
function. We have also amended our audit form to ensure improved justifications are stated for the 
overall scoring of an audit and for each article. This should better ensure there are records setting 
out exactly why the FSIO has deemed it to have been or complied with (or not). 

Over the course of the past two years LFB’s Central Regulatory Enforcement Group have been 
conducting bespoke training for regulatory fire safety team leaders on the management vetting of 
their team’s audit forms and Enforcement Notices to increase team leaders’ knowledge and skills. 
LFB has now brought in additional resources to assist with that and develop and roll out a new 
training package for all staff involved in the management vetting process. We expect to complete 
this over the course of the next six to twelve months. 

Deputy Assistant Commissioner Steve Norman drew your attention to work undertaken to educate 
staff on the risk arising in specialised housing and to our work running a series of external seminars 
for the managers of care homes. LFB’s Fire Prevention and Protection Department (P&P) are 
currently developing a new training needs analysis for LFB’s inspecting officers. Over the next six 
months P&P will conduct a full review of the training and continuous professional development 
(CPD) material used for all forms of vulnerable sleeping risk premises including care homes, extra 
care schemes and sheltered housing and supported living schemes. From this, over the next twelve 
months we will develop and roll out refreshed CPD covering the specific risks arising for these 
premises types. That CPD will be mandatory for all staff involved in the audit of these premises types 
and will form part of mandatory refresher training through our Development and Maintenance of 
Operational Professionalism (DaMOP) framework.  

LFB is also committed to applying the new national scheme of third-party accreditation of the 
competency of fire safety inspecting officers whose work involves the audit or provision of advice to 
higher risk premises. All such staff have achieved or are working towards an NVQ level 4 Diploma 
qualification after which they will be assessed though a new scheme operated by the Institution of 
Fire Engineers in conjunction with the Engineering Council. Achieving this level of accreditation for all 
Fire Safety Inspectors will take some time, potentially four to five years as there is currently a lack of 
approved assessors across the country. We expect the first tranche of Inspectors to be assessed over 
the coming 18 months.   

4. 

No clear and practical guidance exists on how specialist housing operators should 
manage the use of high-risk electrical devices such as portable electric fan heaters. 

Although there is some guidance contained in government approved and National Fire Chief Council 
guidance, we believe this is a matter that should be expanded on as part of the Government review 
of guidance to the public. 

From the London Fire Brigade perspective, use of portable heaters forms part of the considerations 
under our home fire safety visits and the guidance documents we issue for fire safety in the home for 
example https://www.london-fire.gov.uk/safety/the-home/portable-heaters-gas-fires-and-open-
fires/  

We are currently reviewing our own guidance and I have instructed staff to include this issue in that 
review over the course of 2022.  

 
 
 
 
 We also operate a number of primary authority partnerships with housing providers and work with 
the G15 group of providers. Now that the inquest findings are available officers will highlight the 
issue to those we work with. However, you will recognise that under existing terms of lease or 
tenancy, the options for them to act in relation to their tenants may be limited and it is not 
something that my officers have a power to enforce. 

5. 

No clear guidance exists regarding the fitting of digital keypads on doors in specialist 
housing. 

Although there is some guidance contained in government approved and National Fire Chief Council 
guidance, I believe this is a matter that should be expanded on as part of the Government review of 
guidance to the public. However, the forms of locking devices used on the exit from a flat as a private 
dwelling is not something that falls to be regulated under the FSO. Therefore, LFB officers cannot 
enforce against it. This issue does arise from time to time in material and guidance produced in 
respect of ‘secure by design’. We will continue to press for guidance in that regard which does not 
adversely, or potentially adversely, inhibit escape from domestic premises in case of a fire 
emergency.  

6. 

Insufficient emphasis is placed upon recommendations contained within British 
Standards regarding automatic connections to ARCs in fire alarms fitted in specialist 
accommodation. 

The ethos of the FSO is one of risk-based fire safety preventative and protective measures. Under 
Government guidance that does mean that it is not a prescriptive regime. Alternative means can be 
used to demonstrate compliance rather than adherence to a British Standard.   

As an enforcing authority we use British Standards as the benchmarks of good practice. However, we 
cannot necessarily enforce them unless a demonstrable risk arises from failing to comply with them. 
If that were to be the case, then we can and will continue to direct that the appropriate British 
Standard is followed. However, that cannot be done if alternative means to the recommendations of 
the British Standard (or other guidance) have been used and are found, on the day of inspection, to 
apparently be providing an equivalent level of safety. In the latter circumstances an enforceable level 
of risk would not have been identified and so a direction could not be given under article 30 of the 
RRFSO. 

The issue appears to be a lack of a direct enforcement mechanism for British Standards. That is a 
matter my officers have previously raised through the coronial system and with government. If a 
specific requirement is to be enforceable it will require legislative change. We will continue to 
advocate for this in appropriate cases as part of our ongoing work with government, other regulators 
and the sector itself.  

To summarise, along with the action already taken, LFB intends the following further actions: 

1.  Officers plan to attend the premises shortly after the end of the 56 day reply period to 

conduct a regulatory audit under the FSO. 

2.  A clarification of LFB policy expanding the requirement for vetting/review of fire safety 

regulatory audits by managers is to be issued to officers in the next few weeks.  

3.  Over the coming six months LFB will conduct a full review of the training and continuous 
professional development material used for all forms of vulnerable sleeping risk premises 

 
 
 
 
 
 including care homes, extra care schemes and sheltered housing and supported living 
schemes. 

4.  From this work in point 3, over the course of the next twelve months LFB will develop and 

roll out refreshed CPD covering the specific risks arising for these premises types. 

5.  LFB is committed to applying the new national scheme of third-party accreditation of the 

competency of fire safety inspecting officers whose work involves the audit or provision of 
advice to higher risk premises. We expect the first tranche of Inspectors to be subject to 
assessment over the coming 18 months.   

6.  Over the course of 2022 we will review our own guidance offering concerning portable 

electric fan heaters in premises such as these.  

7.  We operate a number of primary authority partnerships with housing providers and work 
with the G15 group of providers. LFB officers will highlight the issue of the use of high-risk 
electrical devices such as portable electric fan heaters to those providers we work with. 

8.  We will continue to press for guidance on fitting of digital keypads on doors in specialist 
housing that will not adversely, or potentially adversely, inhibit escape from domestic 
premises in case of a fire emergency. 

I hope that this satisfactorily explains the actions that have been taken and those which we will 
continue to take to address the concerns raised in your letter. 

Yours sincerely 

London Fire Commissioner

Mr G Irvine  
Acting Senior Coroner 
Walthamstow Coroner’s Court 
Queens Road 
Walthamstow 
E17 8QP 

Sent by email only to:

15 June 2022 

Dear Sir, 

Coroners and Justice Act 2009 
Coroners (Investigations) Regulations 2013 
Regulation 28: Report to Prevent future deaths (Ref: 108578) 
Re: Ashlie Claire Liana Timms, deceased 

As requested, I write in response to the above-mentioned report (Report) and particularly the 
concerns (Concerns) you have raised therein. 

By way of background, the National Fire Chiefs Council (NFCC) is the professional voice of 
the UK fire and rescue services (FRS) and is comprised of a council of UK chief fire officers. 
The NFCC is a membership organisation of FRS senior and strategic managers. Its main aims 
are  to  support  FRS  to  meet  the  changing  demands  on  resources  and  to  maximise 
effectiveness by promoting consistency by highlighting best practice in the sector.1 

For  the  sake  of  clarity,  the  NFCC  is  not  an  enforcing  authority  under  the  principal  fire 
regulations relevant to the premises in issue; it does not have regulatory functions. 

The principal fire regulations applicable to the premises can be found in the Regulatory Reform 
(Fire Safety) Order 2005 (the Order).2 Article 25 of the Order provides—for the purposes of 
the  Order—the  meaning  of  an  ‘enforcing  authority’.  One  of  the  enforcing  authorities  within 
Article 25, is the fire and rescue authority, which is the corporate entity of the FRS pursuant to 
Section 1 of the Fire and Rescue Services Act 2004 (as amended),3 in which the premises are 
located. 

1 Further information can be found here: National Fire Chiefs Council (NFCC) 
2 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 
3 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 

Page 1 of 6 

15 June 2022 

 
 
  
 
 Enforcing authorities are required to enforce the provisions of the Order and any regulations 
made  under  Article  24  in  relation  to  premises  for  which  they  are  the  applicable  enforcing 
authority.4 In doing so, they must have regard [emphasis added] to guidance issued by the 
Secretary of State.5 Further reference to this statutory guidance is amplified hereunder. 

The NFCC, whilst not an enforcing authority under the Order, is able to contribute, encourage 
and steer, within reason, the strategic and operational functions, and activities of FRS, as they 
relate, among other things, to fire safety and protection, and the relevant statutory duties to 
enforce the Order. 

The following is provided to take account of each Concern. This regrettably requires, for the 
avoidance  of  doubt,  repetition.  The  NFCC  considers  this  favourable  to  assist  with,  among 
other  things,  future integrity  of this response,  should this  document  be  later  fragmented  by 
design, or otherwise, and reproduced elsewhere. 

For ease of reference, the following uses the same numbering for Concerns as set out in the 
Report. 

1. The operator of the premises failed to ensure that staff on duty were competent to 
carry out a fire evacuation. Despite reflection and remediation in policies, processes 
and  training,  multiple  staff  members  who  gave  evidence  to  the  inquest,  remained 
unable to describe the proper action to take in the event of a fire alarm. 

The NFCC replaced the Chief Fire Officers Association (CFOA) which were a participant in 
the production of HM Government Fire Safety Risk Assessment in Residential Care Premises 
20076. This document recognises, among other things, that relevant practical staff training, in 
evacuation procedures in the event of a fire, is vital in environments where residents of care 
homes have complex physical, sensory, and cognitive needs. 

In 2017 the NFCC, along with many stakeholders, co-operated to produce the Fire Safety in 
Specialised Housing Guide7. This document provides guidance on evacuation in supported 
living and other specialised housing. 

The NFCC represent FRS on various British Standards Institute (BSI) committees and other 
groups such as National Social Housing Fire Safety Group. 

Further,  and  perhaps  more  importantly  in  this  case,  the  NFCC  meet  with  the  Care  Quality 
Commission  and  other  interested  parties,  regarding  fire  safety  standards  in  higher  risk 
accommodation. 

Action 

1.  The NFCC undertakes, at the earliest opportunity, to seek to ensure that this Concern 
is reported into these committees to encourage debate and petition for such positive 
outcomes necessary, and as far as is achievable under this action by the NFCC, to, it 
is hoped, assuage your apprehension to this Concern. 

4 Article 26 Regulatory Reform (Fire Safety) Order 2005 
5 Article 26(2) Regulatory Reform (Fire Safety) Order 2005 
6 See: Fire safety risk assessment: residential care premises - GOV.UK (www.gov.uk) 
7 See: NFCC_Specialised_Housing_Guidance_-_Copy.pdf (nationalfirechiefs.org.uk) 

Page 2 of 6 

15 June 2022 

 
 
 
 2.  The NFCC will send a copy of your Report annexed to a copy of this response, to all 
FRS in England to bring your Concerns to their respective attention, and to inform the 
FRS of the NFCC’s proposed actions. This should provide an excellent opportunity to 
direct  information  regarding  the  Concerns  and  the  NFCC’s  response,  into  the 
corporate mind and strategic management forums of the FRS. 

2. Fire alarms in three units operated by Sequence Care Group remain non-compliant 
with the 2013 British Standard Guidance, which recommends that they should have a 
link to an Alarm Receiving Centre (“ARC”) which automatically contacts the emergency 
services when an alarm is activated. 

The NFCC represent FRS on BSI committees including the overarching committees for fire 
detection and alarm systems (FSH12) and fire precautions in buildings (FSH14). 

Action 

1.  The NFCC undertakes, at the soonest opportunity, to seek to ensure that this Concern 
is reported into these committees to encourage debate and petition for such positive 
outcomes necessary, and as far as is achievable under this action by the NFCC, to, it 
is hoped, assuage your apprehension to this Concern. 

3.  The  London  Fire  Brigade  conducted  fire  safety  audits  at  the  premises  which 
assessed the unit as displaying the highest standard of fire safety compliance. These 
findings were found to be entirely incongruent with procedures, equipment and staff 
training  in  place  before  and  at  the  time  of  the  fire.  The  London  Fire  Brigade  have 
reviewed and changed processes since 2018 but they remain incomplete. 

The former  CFOA  provided the  audit  framework  that  FRS  adapt  to  their  own local  working 
practices. This is reviewed regularly and is now due for a full review and improvement following 
the recent introduction of new fire related legislation which will affect the FRS audit process.8 

The NFCC is heavily involved with the, relatively new, Fire Standards Board (FSB). The FSB 
was  founded  to  oversee  the  identification,  organisation,  development,  and  maintenance  of 
professional standards for fire and rescue services in England. 

The FSB is responsible for approving standards and the approach to their development. It sets 
the  priorities  for  standards  development  work.  And  commissions  work  based  on  proposals 
from third parties, monitors progress with ongoing work and approves completed work. 

Further, it seeks to ensure that any standards presented for approval have been developed in 
line with the agreed development process, undergone appropriate consultation with subject 
matter experts and relevant stakeholders and undergone an independent quality assurance 
process. 

The FSB meets at least four times per year; all papers are published on its website.9 

8 See: Fire Safety Act 2021 (legislation.gov.uk) and Building Safety Act 2022 (legislation.gov.uk) 
9 See: Fire Standards Board 

Page 3 of 6 

15 June 2022 

 
 
 
 Her  Majesty’s  Inspectorate  of  Constabulary  and  Fire  &  Rescue  Services  (HMICFRS)10 
independently assesses and reports on the effectiveness and efficiency of FRS. 

The HMICFRS draws upon its inherent expertise to interpret the evidence derived from the 
assessments of FRS to make recommendations for improvement. 

Action 

1.  The NFCC will redouble its efforts in progressing such work mentioned above and that 
it is responsible for. This extends to influencing the content of new or amended fire 
protection and safety standards. The NFCC is also currently leading the review of the 
competency framework for Fire Safety Regulators (which includes FRS inspecting and 
enforcement officers) and enforcement toolkit for high rise buildings and have in the 
past  year  launched  a  third-party  professional  accreditation  scheme  for  Fire  Safety 
Regulators  and  a  national  learning  platform  to  underwrite  the  continual professional 
development of such officers. 

2.  The  fire  sector,  in  the  wake  of  the  Grenfell  fire  tragedy,  is  receiving  the  closest  of 
scrutiny, review and reform—much of which is being driven by HM Government—and 
the NFCC is subject to the dynamic and varying demands and challenges flowing from 
these activities. The NFCC respectfully submits, therefore, that there is some difficulty 
in  offering  a  timetable  to  complete  this  action,  other  than  to  say  that  it  is  receiving 
dedicated and continual attention by the NFCC, with an expectation of delivery within 
the upcoming months. 

3.  The NFCC will continue to support the FSB with its undertakings. 

4.  The NFCC will continue to support the HMICFRS with its undertakings. 

4. No clear and practical guidance exists on how specialist housing operators should 
manage the use of high-risk electrical devices such as portable electric fan heaters. 

Pursuant  to  Article  50  of  the  Order,11  the  Secretary  of  State  must  ensure  that  guidance 
(Guidance)  is  issued  to  assist  those  responsible  for  fire  protection  and  fire  safety  within 
premises  to  which  the  Order  applies.  A  full  review  and  improvement  of  the  Guidance  is  in 
progress and is being superintended by the Home Office. 

Notwithstanding this, it is the view of the NFCC that the Guidance, regarding care homes and 
the NFCC Specialised Housing Guide, whilst not being statutory in nature, does satisfactorily 
address this Concern.12 

Action 

1.  The NFCC is in the process of carrying out a significant programme of work, much of 
which is closely aligned and in collaboration with, the Home Office and the Department 
for Levelling Up, Housing and Communities. It is also working closely with the Care 
Quality Commission13 to formalise the use of ‘Person Centred Fire Risk Assessments’ 
(PCFRA) by care provider companies as part of care planning processes. Similarly, 

10 See: HMICFRS - Home (justiceinspectorates.gov.uk) 
11 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 
12 See: NFCC_Specialised_Housing_Guidance_-_Copy.pdf (nationalfirechiefs.org.uk) 
13 See: Care Quality Commission (cqc.org.uk) 

Page 4 of 6 

15 June 2022 

 
 
 
 local authorities, housing providers and their fire risk assessors are being encouraged 
to apply PCFRA to new residents upon the granting of leases or periodic tenancies. 
The NFCC believe these innovative interventions will increase the likelihood of such 
risks being identified and addressed in future. 

2.  This work includes the Guidance review and improvement, and the NFCC will continue 
to  work  with  the  Home  Office  to  make  sure  that  the  matter  of  Concern  is  suitably 
addressed in any Guidance revision. It should be noted that any revision is subject to 
drafting and consultation, with an expectation of being issued in early 2023. 

5.  No clear  guidance exists regarding  the  fitting  of  digital  key-pad locks  on  doors in 
specialist housing. 

Pursuant  to  Article  50  of  the  Order,14  the  Secretary  of  State  must  ensure  that  guidance 
(Guidance)  is  issued  to  assist  those  responsible  for  fire  protection  and  fire  safety  within 
premises to which the Order applies. A full review and revision of the Guidance is in progress 
and is being superintended by the Home Office. 

Notwithstanding this, it is the view of the NFCC that its own guidance, contained in the NFCC 
Specialised Housing Guide, whilst not being statutory in nature, does satisfactorily address 
this Concern. 

Action 

1.  The NFCC is in the process of carrying out a significant programme of work, much of 
which is closely aligned and in collaboration with the Home Office and the Department 
for Levelling Up, Housing and Communities. 

2.  This work includes the Guidance review and improvement, and the NFCC will continue 
to work with the Home Office to make sure, as far as is reasonably practicable, that 
the  matter  of  Concern  is  suitably  addressed  in  any  Guidance  revision.  It  should  be 
noted that any revision is subject to drafting and consultation, with an expectation of 
being issued in early 2023. 

6.  Insufficient  emphasis  is  placed  upon  recommendations  contained  within  British 
Standards regarding automatic connections to ARCs in fire alarms fitted in specialist 
accommodation. 

The NFCC represent FRS on BSI committees including the overarching committees for fire 
detection and alarm systems (FSH12) and fire precautions in buildings (FSH14). 

Action 

1.  The NFCC undertakes, at the soonest opportunity, to seek to ensure that this Concern 
is reported into these committees to encourage debate and petition for such positive 
outcomes necessary, and as far as is achievable under this action by the NFCC, to 
assuage your apprehension to this Concern. 

14 See: The Regulatory Reform (Fire Safety) Order 2005 (legislation.gov.uk) 

Page 5 of 6 

15 June 2022 

 
 
 
 Conclusion 

In closing I wish to provide you with my assurance that the NFCC will attend to, and expedite 
the actions set out above, with due diligence, care, and close attention. 

I trust that you find all in order with this response and that you consider the NFCC proposed 
actions  contained  herein—as  far  as  they  can  be  addressed  by  the  NFCC—suitable  in 
addressing  the  Concerns.  And,  further,  that  you  are  satisfied  that  the  relevant  duty  for  the 
NFCC to respond to your Report has been properly discharged. If this is not the case or, if you 
require anything further from the NFCC, please do not hesitate to contact my colleague Roy 
Unit 
Protection 
Carter 

Reform 

NFCC 

Policy 

within 

and 

the 

Yours faithfully, 

. 

Chair 
National Fire Chiefs Council 

Page 6 of 6 

15 June 2022