Frederick Powell

Mr P Cooper 
HM Assistant Coroner, Lincolnshire 
The Myle Cross Centre 
Macaulay Drive  
Lincoln LN2 4EL 

Dear Mr Cooper, 

18 December 2023 

Frederick Powell deceased, 20 St Martin’s Close, Blyton  

This response is provided by Acis Group Limited (‘AGL’) in relation to the Regulation 28: Report 
to  Prevent  Future  Deaths  dated  24  October  2023  received  from  HM  Assistant  Coroner  for 
Lincolnshire because of Frederick Powell deceased’s death on the 6 September 2023, at the 
property  known  as  20  St  Martin’s  Close,  Blyton  (‘the  property’),  which  is  a  general  needs 
bungalow. 

Frederick Powell deceased (‘the resident’) occupied the property as a tenant of AGL under an 
Assured Tenancy that commenced on 11 September 2006.  The resident was 93 years of age 
at  his  death  and  had  been  a  tenant  with  AGL  since  1986,  having  occupied  an  alternative 
property also let by AGL, before his move into the property in 2006. 

On 6 September 2023 the resident was the subject of a tragic incident which occurred when he 
fell  through  an  internal  door  which  contained  non-toughened  glazing,  resulting  in  his 
subsequent death from his injuries.   

AGL was advised by Lincolnshire Police that the resident had been discharged from hospital 
on  25  August  2023  where  he  had  been  receiving  treatment  for  Plural  Effusion  query 
Mesothelioma and that the resident had various other ailments including frailty and dementia, 
the result of which was that the resident was reported to have been unstable on his feet.  The 
resident had been sleeping in his recliner chair, which was situated in the living room of the 
property, as he had been awaiting a specialist bed to be delivered.  AGL had not been informed 
of the resident’s discharge from hospital and so at the time of the resident’s death were unaware 
of the circumstances. 

The Matter of Concern identified within the Coroner’s Report was: 

‘’Although it is not suggested current building regulations were breached the Inquest 
was told many more properties in your stock retained internal glass doors. Is it time for 
a review to reconsider replacement?’’ 

Prior to receiving the Regulation 28 Report To Prevent Future Deaths from the Coroner, AGL 
had already  been working  proactively to address the  concern later raised by  the Coroner  in 
relation to internal glazing on their housing stock, for example in 2020 AGL’s Lettable Standard 
(the specification to which an empty property must meet prior to being re-let) was revised and 
included specific provision to replace or encapsulate single glazing prior to the re-letting of an 
empty property.    

(Cont’d) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  relation  to  the  specific  property,  it  was  constructed  in  1967  and  met  all  relevant  Building 
Regulations at that time of construction and build.  The decorative glass door and panel were 
original features of the property, with the requirement to provide toughened safety glazing only 
coming in with subsequent changes to the Building Regulations.  It is important to also note 
that any changes to Building Regulations do not apply retrospectively.   

The property also met the Regulator of Social Housing’s Decent Homes Standard, and AGL 
was  not  on  notice  of  any  defect  relating  to  its  repair  and  maintenance  obligations,  either  in 
general or specifically in respect of the glazed door.  Whilst AGL was aware of the presence of 
this type of glazing in some of its properties, the inherent risk was considered to be low, and 
therefore AGL initiated a policy to address it over time, as and when those properties with that 
type of glazing became empty, thus being picked up through the Lettable Standard.   

Following  the  tragic  circumstances  of  the  resident’s  death,  AGL  has  publicly  expressed  its 
condolences to the resident’s family and friends.  AGL also immediately undertook an exercise 
to identify any other properties within AGL’s stock that might also incorporate internal single 
glazed doors and/or panels and an action plan has been set out to address those properties 
based on information held by AGL around the tenant’s age and health needs (where known) in 
order to prioritise a proactive programme of improvements based on the risk-based profile of 
the tenants.    

AGL has started to contact those customers, by priority banding.  As part of this process, AGL 
is offering information, advice and guidance to its tenants, and is also discussing all possible 
actions to replace or encapsulate any identified glazing.  AGL expects that the proactive contact 
with its tenants will be concluded by the end of March 2024, albeit that any resultant remedial 
actions  will  take  longer,  and  will  be  contingent  upon  AGL’s  tenants  consenting  to  the  works 
being undertaken.    

AGL  has  also  invited  tenants  with  any  concerns  over  glazed  doors  in  their  homes  to  make 
contact.    AGL  has  reached  out  via  its  own  website,  its  “MyAcis”  digital  customer  portal, 
telephone  calls  by  its  Customer  Service  Centre  to  its  tenants,  and  by  making  home  visits.  
Those actions will enable AGL to provide advice and support to its tenants, and to also bring to 
light  any  properties  that  might  have  that  type  of  door  installed,  but  not  recorded  on  AGL’s 
database, whether as an original fixture, or because of tenants undertaking DIY and replacing 
doors.  Depending upon the source of the door, and time of installation, AGL will either add it 
to a planned remediation programme or signpost the tenant to other resources in cases where 
the tenant has installed the door themselves during their tenancy.  

Like  many  of  AGL’s  peers,  the  stock  condition  survey  programme  has  previously  focused 
predominantly on Decent Homes Standard compliance, and the age and condition of relevant 
components within a property; this would include external windows and doors but did not focus 
on internal glazing.  Since being notified of the incident we immediately added the presence of 
internal glazing to our data capture requirements of the stock condition survey meaning that 
this information will now be gathered over the stock condition survey cycle if it is not already 
known  or  has  otherwise  been  identified.    Should  further  properties  be  identified  through  our 
stock condition survey programme over the next cycle, they will be dealt with on a case-by-
case basis, as they arise. 

AGL has also engaged a specialist contractor to assist with the delivery of remedial works which 
will  be  prioritised  based  on  risk.    Initial  pre-works  surveys  are  planned  to  commence  in 
December 2023 with any urgent remedial works to immediately follow.  

The Board of Acis Group Limited has been kept fully appraised of the position, and AGL asserts 
that there had been no breach of any Regulatory Standards or statutory obligations in respect 
of our repair and maintenance responsibilities., However, AGL took the decision to refer the 
issue to the Regulator of Social Housing in order to ensure that they too were fully appraised 
of the matter and the action that AGL has taken, and continues to take in response to it.   

(Cont’d) 

 
 
 
 
 
 
 
 
 
 
 In  addition,  AGL’s  Chief  Executive,  with  the  approval  of  the  Board,  contacted  the  National 
Housing Federation (NHF), asking for their support to cascade information to raise awareness 
amongst  the  social  housing  sector.    The  NHF  represents  its  housing  association  members 
across  England  (who  collectively  provide  homes  for  around  six  million  people)  and  uses  its 
knowledge and leadership to shape national policy and represent the views of the sector to the 
government and key decision makers. 

AGL contacted the NHF because it recognised that the presence of this type of glazing was not 
unique to  AGL and was in  fact widespread across the UK’s housing stock, not just in social 
housing, but across private rented properties and privately owned residences too.   

AGL have made this report to both the Regulator and the NHF  to bring their attention to this 
incident and our response to it, and to raise awareness within the social housing sector so that 
AGL’s experience may enable other Registered Providers to take necessary measures in order 
to prevent future deaths. 

AGL believes that this is a proportionate response to the matters raised by the coroner insofar 
as they relate to AGL’s stock.  

If there is any further information that you require at this stage in relation to the reported incident 
or our approach to the wider issue, then please do not hesitate to telephone or email me directly. 

Yours sincerely 

Chief Executive, Acis Group Limited