Paul Keating

Deputy Director 
Fire Safety Unit  
Home Office 
2 Marsham Street  
London SW1P 4DF  

20 September 2023 

Oliver Longstaff  
Coroner’s Service 
West Yorkshire (Eastern) Area 
71 Northgate 
Wakefield 
West Yorkshire 
WF1 3BS 

Dear Oliver, 

Regulation 28: Report to prevent future deaths 

I refer to your report dated 25 July 2023 provided in accordance with your 
duty under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, 
following your inquest into the very sad death of Mr Paul Keating. I offer my 
sincerest condolences to the family and friends of Mr Keating.  

I understand from your report that the inquest concluded that Mr Keating died 
from a fire in his home, which was found to have likely been caused by the 
discarding of smoking materials. You have raised concern regarding the fire 
risks that arose as a consequence of the local authority not having the 
necessary powers to enter Mr Keating’s flat to install fire safety precautions 
when entry is denied. 

In your report you refer to the Regulatory Reform (Fire Safety) Order 2005 
(FSO). The purpose of the FSO is to regulate fire safety in workplaces and the 
communal parts of multi-occupied -domestic premises (the ‘common parts’). 
The FSO is not intended to regulate fire safety inside individual private 
dwellings. 

In the case of social housing such as Mr Keating’s, the Housing Health and 
Safety Rating System (HHSRS) applies. The HHSRS, set out in secondary 
legislation under the Housing Act 2004 and introduced in 2006, is a technical 

 
 
 
 
 
 
 
 
 
 
   
 
     
 
  
 
 
 
 
 
 
 
 risk-based tool used by local authorities to assess the condition of residential 
premises. It can be applied to a whole building (e.g. all private dwellings and 
all common parts) or to part of a building (e.g. an individual private dwelling). 
An HHSRS assessment covers 29 potential hazards, including fire, and 
categorises them by seriousness. 

The Decent Homes Standard sets the minimum standards that social homes 
are required to meet. To meet it, the standard that all social housing (including 
local authority-owned stock) must achieve, a dwelling must be free from 
hazards at the most dangerous ‘category 1’ level that is assessed using the 
aforementioned HHSRS. In addition, where a dwelling is privately rented or 
rented from a housing association, local authorities have a duty to enforce if 
they identify category 1 hazards, and a discretionary power to enforce where 
less serious category 2 hazards are assessed. The decision whether to 
enforce in respect of a category 2 hazard should be taken in accordance with 
the local authority’s enforcement policy. The actions available to the local 
authority include powers to require remedial works, prohibit the use of part or 
all of a building or carry out emergency works themselves. 

Turning to the specific issue of the local authority’s ability to access the 
property to carry out works, the Pre-Action Protocol (PAP) for Housing 
Conditions Claims (England) has been published by the Ministry of Justice to 
promote the speedy and appropriate carrying out of any remedial works which 
are the landlord’s responsibility and avoid unnecessary legal action. Section 
7.6 of the PAP, which relates to access, states that ‘Tenants must allow the 
landlord reasonable access for inspection and the carrying out of works in 
accordance with the tenancy agreement’.  

Also relevant is the important role that Fire and Rescue Authorities (FRAs) 
must play in relation to the prevention of fires and ensuring public safety. 
Section 6 of the Fire and Rescue Services Act 2004 requires FRAs to make 
provision to promote fire safety in its area. FRAs meet this requirement 
through a range of activity, including through Home Fire Safety Visits.  These 
visits see fire service personnel visit vulnerable people in their own homes to 
provide them with tailored fire safety advice. Where risks are identified which 
cannot be addressed by the FRA, they will work closely with other local public 
services, such as multi-agency safeguarding hubs, to ensure appropriate 
action is taken. 

The Home Office also funds the Fire Kills campaign to promote domestic fire 
safety messages to the general public, and particularly those groups we know 
to be most at risk should a fire in the home occur. The campaign raises 
awareness of the importance of installing and regularly testing smoke alarms 
and, crucially, the behaviours and actions they can take to reduce the risk of a 
domestic fire.  

Taken together, these measures provide a basis for action to be taken and 
support residents, such as Mr Keating, with improving fire safety.  

Yours sincerely, 

 
 
 
 
 
 
 
 
 Deputy Director 
Fire Safety Unit 
Home Office

Oliver Longstaff 
HM Area Coroner - West Yorkshire (Eastern) 
Wakefield Coroner’s Court 
71 Northgate 
Wakefield 
WF1 3BS 

Sent by email 

Customer Relations 
FREEPOST RLZR-ELTX-RUEH 
Leeds City Council 
PO Box 657 
Leeds 
LS1 9BS 

Date: 06 September 2023 

Dear Mr Longstaff 

Inquest into the death of Paul Keating 

Regulation 28 Report to Prevent Future Deaths 

Thank you for your report dated 25 July 2023 in respect of concerns arising out of the 
inquest into the sad death of Mr Keating on 15 April 2023.  I write to respond to that report on 
behalf of the Council. 

I would firstly wish to say that I was very sad to hear of the fact and circumstances of Mr 
Keating’s death and would wish to pass on my condolences to his family and all those 
affected by these events. 

As your report recognises, since 2017 Leeds City Council has adopted a proactive approach 
to improving fire safety within its tower blocks, following the Grenfell tragedy.  This included 
installing sprinkler systems in those tower blocks.  These sprinklers are intended to cover not 
only the common parts of the buildings, which fall within the scope of the Regulatory Reform 
(Fire Safety) Order 2005 (as amended by the Fire Safety Act 2021), but also individual flats 
within the blocks, which are outside the scope of the 2005 order. 

Regrettably despite the Council’s extensive efforts to obtain access for the installation of 
sprinklers into Mr Keating’s flat, no such access was given, as your report outlines. 

Because the works to install sprinklers would be deemed to be improvement works rather 
than repair or emergency works, and because sprinklers are not currently a legal 
requirement inside individual flats, the Council did not have legal powers to gain entry 
against Mr Keating’s wishes to carry out these works.  This is the main area of concern 
raised in your report. 

www.leeds.gov.uk 

 
 
 
                   
 
                   
 
                   
 
                   
  
                   
 
 
 
  
 
 
 
  
 
 
 
                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 The granting of additional legal powers to landlords, in order to permit them to carry out 
safety works without the tenant’s consent, is a matter over which the Council has no control 
but falls to be considered by central government, and I note that the report was also 
addressed to the Home Office.  I would however like to endorse your concerns as expressed 
in paragraphs 5 and 6 of the Matters of Concern. 

A copy of this response will be provided to the Home Officer for their information. 

I would like to thank you again for your report raising these concerns. 

Yours sincerely 

Chief Officer - Housing 

www.leeds.gov.uk