Gabrielle Steel

Nadia Persaud 
Area Coroner  
Walthamstow Coroner’s Court 
124 Queens Road 
Walthamstow  
E17 8QP  

Adults and Health (DASS) 
London Borough of Newham 
1000 Dockside Road 
London 
E16 2QU 

29 November 2024 

Our ref: 

Dear Ms Persaud 

Re: Regulation 28 Report concerning Gabrielle Sarah Anne Steel 

Response from the London Borough of Newham  

Thank you for sharing the conclusion of your Inquest into the death of Gabrielle Sarah Anne Steel, 
and  the  subsequent  Regulation  28  Report.  May  I  start  by  expressing  my  sincere  regret  and 
disappointment  to  learn  of  the  circumstances  surrounding  Ms  Steel’s  passing.  On  behalf  of  the 
Council I wish to place on record our deepest condolences to her family, her friends and all those 
that knew her. We fully acknowledge the findings from the Inquest and are fully committed to putting 
actions in place to address the concerns raised in the Prevention of Future Deaths report. 

A core group of Senior Officers from the department were involved in a detailed review of Ms Steel’s 
case  following  her  death.  The  review  resulted  in  an  action  plan  with  a  focus  on  prevention,  this 
emphasised a number of interventions including smoking cessation.  We have updated our action 
plan following the Inquest findings; please see below for details of this. 

Action: 

1  A reflective case discussion at the Fire Safety 
Group on 10/12/24. The Fire Safety Group is 
the multi-agency group responsible for fire 
safety issues in the Borough. This discussion 
will involve a review of previous reflective 
sessions 

2  To further improve training for social care 
staff by holding a training session on fire 
safety risk assessment and risk management 
plans. This session will complement the joint 
training session which took place on 25/04/24 

3  Produce a ‘7 minute briefing on the 

development of fire safety risk management 

By who: 
Strategic 
Safeguarding Adviser 

By when: 
10/12/24 

Workforce 
Development and 
Strategic 
Safeguarding 

30/01/25 

Workforce 
Development and 

24/12/24 

Page 1 of 3 

       
 
 
 
 
 
 
 
 
 
 
 
 
 plans. The 7 minute briefing will address the 
following issues: 

1)  Escalation procedures regarding 

Strategic 
Safeguarding  

fire risks 

2)  How to obtain feedback from LFB 
about fire safety risk assessments 
3)  Reviews of risk assessments and 

risk management plans 

4  Enhanced monitoring where there is an 

established risk of fire for people known to 
Adult Social Care. The monitoring will take 
place for the next year with the objective of 
ensuring learning is embedded 

Strategic 
Safeguarding 

Monitoring to start 
from 2025 

Governance and Oversight    

The following people have been sighted on the action plan:  

• 
• 
• 
• 

Corporate Director of Adults (DASS), Commissioning, Health & Social Care 

-Director of Quality Assurance, Safeguarding and Workforce Development 

-Head of Service - Older People & Disability, Operations 

-Head of Service - Older People & Disability, Operations  

All elements of the plan are linked to specific teams with accountability for their delivery. Oversight 
of  the  action  plan  is  being  held  by  the  Strategic  Safeguarding  Team  who  will  monitor  progress 
against the stated timescales and then report back to the Directorate Management Team. We also 
recognise that the overall plan will need to remain agile and be adapted if further information comes 
to light  

Thank you again for raising this matter with us. I hope this response gives adequate assurance on 
the actions we have taken on the improvements required.    

Please do not hesitate to come back to me if you require further information or updates.   

Yours sincerely, 

CC: 

Chief Executive 
Corporate Director of Adults and Health  
Director of Change, Improvement and Control  

Page 2 of 3 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Director of Quality Assurance, Safeguarding and Workforce Development 
Head of Law (Community)     

Page 3 of 3

London Fire Brigade Headquarters 
169 Union Street London SE1 0LL 
T 020 8555 1200  
london-fire.gov.uk 

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

Date 29 November 2024 
Ref: 

Area Coroner N Persaud 
East London 
124 Queens Road 
Walthamstow 
E17 8QP  

Dear Coroner 

Response to Regulation 28 Report to Prevent Future Deaths 

I write in response to the Regulation 28 report to prevent future deaths, which you issued following the 
inquest touching the death of Mrs Gabrielle Steel. 

London Fire Brigade (‘LFB’) actions to address concerns following the inquest. 

2. 

The findings of the home fire safety visit were shared only with Mrs Steel – a 
vulnerable, elderly lady. The findings were not conveyed to those with responsibility 
for caring for her. 

Existing LFB policy, which follows national best practice, does not authorise staff to share findings with 
any other person.  Providing staff are satisfied that the individual recipient is able to understand and 
retain the advice given, they share advise and observations face to face.  During the booking of Mrs 
Steel’s Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and 
retain the information provided – this was noted on our records and therefore the crews followed the 
correct process as outlined in the policy.  

Noting HM Coroner’s observations, we have started to review our processes and have engaged with 
our Information Management Team to discuss the data protection issues around sharing information 
with third parties where the resident has full mental capacity. LFB are reviewing the data protection 
privacy impact assessment and consulting the Information Commissioner to fully scope how we can 
best meet this need while ensuring privacy for the resident.  

LFB are reviewing the questions asked at the point of booking the visit to ensure that information is 
gained regarding whether there is the provision of care in the home and recommend that the carer 
attends the visit. LFB are also considering the best ways of communicating with the carer or family 
member if they are not present, for example leaving guidance in the property including information 
about flame retardant bedding where appropriate. 

Following this review LFB will where necessary update the policy, guidance, and training to ensure all 
staff carrying out Home Fire Safety Visits fully understand this process. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 3. 

A written risk assessment/risk assessment plan was completed by the London Fire 
Brigade. This was not left in the property or shared with Mrs Steel, her family, her 
carers, or the agency who requested the fire safety check. 

The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making 
or contributing to a personalised risk management plan for an individual resident.  The purpose of a 
Home Fire Safety Visit is to provide advice and guidance to help keep the resident safe. At a Home Fire 
Safety Visit, LFB staff record advice given on a data collection form which is then uploaded into a 
database. In most cases this information is recorded using a tablet which will populate the database 
automatically. Existing LFB policy, which follows national best practice, does not authorise staff to 
share findings with any other person and currently no functionality to be able to leave a copy of the 
findings with the resident. 

The policy currently states that a Home Fire Safety Visit guide with generic advice will be left with the 
resident, however this would not contain bespoke advice given for example around flame retardant 
bedding and the importance of always keeping it on the bed. 

LFB are scoping options for being able to leave bespoke information with the resident, and with family 
members or a carer where appropriate. This includes engagement with the National Fire Chiefs 
Council and other Fire and Rescue Services to identify any areas of best practice. Following this review 
LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out 
Home Fire Safety Visits fully understand this process. 

4. 

As a result of the poor communication from the LFB, there was no risk management 
plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire 
assessor been communicated, carers would have been aware of the need to re-
iterate the importance of stubbing out cigarettes in an ashtray and not leaving 
cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to 
ensure that safe bedding was in place at all times; the importance of keeping 
extraneous flammable materials away from the bed; as much as possible. 

The Fire Service’s statutory role does not include responsibility for a resident’s care plan or for making 
or contributing to a personalised risk management plan for an individual resident. Home Fire Safety 
Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the 
resident. Care providers are regulated to plan and deliver care based on risk assessments, and this 
should include assessing risk from fire. A care provider should not need a HFSV to prompt attention on 
any of the points raised above. However, we accept that there is learning around communication with 
the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for 
the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set 
out above that we are taking steps to explore improvements.  

LFB has been working to educate carers on a local and pan-London level for several years. There is 
information for carers on the LFB website and an intranet page with resources for staff to use. LFB have 
an established relationship with the Care Quality Commission (CQC). The NFCC Person Centred Fire 
Risk Assessment form is a tool for carers to use to identify and mitigate fire risk for the people they care 
for. This form is in the process of being updated. The CQC are committed to sharing this information 
with the care industry. 

LFB will engage with Local Authorities to share the learning from this report and reiterate the role of 
the carer in reducing fire risk. LFB will also share the learning from this report, and our subsequent 
actions to improve our processes, with other Fire and Rescue Services through the NFCC National 
Organisational Learning process. 

LFB is committed to improving fire safety provisions for vulnerable people who may be in receipt of 
care across London, with the aim of reducing the number of fires that result in death or serious injury.   

 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Deputy Commissioner