Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0643, written 22 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2024 |
|---|---|
| Reference | 2024-0643 |
| Deceased | Muhammad & Naemat Esmael |
| Coroner | Kirsten Heaven |
| Coroner area | Swansea and Neath Port Talbot |
| Category | Wales prevention of future deaths reports (2019 onwards) · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 Act, and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, where an investigation gives rise to concern that future deaths will occur, and the investigating coroner is of the opinion that action should be taken to reduce the risk of death, the coroner must make a report to the person the s/he believes may have the power to take such action. These prevention of future deaths reports are known as PFDs. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cabinet Secretary for Housing and Local Government Welsh Government 5th Floor Tŷ Hywel Cardiff Bay CF99 1SN Email: Head of Mid and West Wales Fire and Rescue Service Service Headquarters, Lime Grove Avenue, Carmarthen, SA31 1SP Email: 1 CORONER I am Kirsten Heaven, Assistant Coroner, for the coroner area of SWANSEA & NEATH PORT TALBOT 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 On 1 July 2023 a fire started in an upstairs bedroom of . When the fire started the door to the bedroom was shut and inside the bedroom was Muhammad Esmael, who was three years of age. Muhammad’s father, Naemat Esmael, was in the adjacent bathroom having a shower. Muhammed’s mother, Sharmeen Ahmed, had left Muhammad with his father in the parents’ bedroom and had gone downstairs. After being downstairs for a very short period of time, Mrs Ahmed heard what sounded like a ball being kicked on a wall and she went to look up the stairs. Mrs Ahmed also heard a couple of beeps from the fire- alarm. On looking up the stairs Mrs. Ahmed saw in the upstairs hall mirror a fire on the ceiling of the bedroom in which Muhammed was located (although she did not know that he was in there). The door to the room was closed. Mrs. Ahmed shouted to alert Naemat and her daughter and her daughter ran out of the property. Naemat came straight out of the shower and ran into the bedroom where Muhammad was located, and the door banged shut behind him. Mrs Ahmed went to ring for help. Naemat was unable to save Muhammad and was forced to jump out of the bedroom window. Tragically both Naemat and Muhammad died because of the fire. The property was leased to the family by Swansea Council. Swansea Council carried out all the appropriate inspections, including electrical inspections, prior to leasing the property to the family. The property contained two smoke alarms, one in the downstairs hallway and one in the upstairs hallways, as required by Welsh Government legislation. The smoke alarms had been replaced in 2020 and were not due to be replaced until 2025. Swansea Council had tested the smoke alarms, and I am satisfied that the smoke alarms were in good working order when the property was leased. The smoke alarms were appropriately hard wired into the mains electricity and the lighting circuit. I therefore find that the smoke alarms were working at the time of the fire but that they did not sound either because the fire had started in a sealed room behind a door closed which meant that no smoke could get to and activate the upstairs fire alarm or that the electricity circuit had tripped and deactivated the fire alarms where those alarms possibly had insufficient battery power. During the investigation, there were only two possible causes for the fire found at the property and these were smoking and electrical. I find that smoking did not cause the fire as there was no evidence that anyone smoked within the property. There was evidence within the property (including within the bedroom where the fire started) that someone had carried out unauthorised electrical works that fell below the standards of a competent electrician. Some unauthorised electrical alterations had been carried out in the property by Naemat Esmael. Swansea Council did not know about these electrical works and so had not authorised them. In the front bedroom where the fire started a two-way extension lead had been directly wired into a double electrical socket behind a wardrobe. Plugged into this extension lead were a games console and a six-way extender lead. A TV was plugged into the six-way extender lead. The cable of the extension lead was fed into the rear of a console unit through an area that had been cut out. The extension leads were housed within a drawer in the console unit and the TV was sat on the console unit. When the drawer was inspected there was evidence of uneven burn patterns within the drawer. There was also evidence of a circular burn pattern that was below the surface where the TV sat and charring to the underside of the console where the TV sat. The console unit and electrics were removed before they could be fully inspected by all the investigators instructed to investigate, including the Chartered Electrical Engineer. The charring and burn pattern around the console unit indicates that something had been on fire within the drawer. The two-way socket, the extension leads, the TV and games console were forensically examined after the fire and there was no evidence of any electrical fault with these electrical items. I therefore find that the fire was not caused by an electrical fault from these items. However, I do find that the fire probably started in or around the console unit. I also find that the fire was probably electrical in origin because there is no other explanation for the fire but also because Mrs Ahmed heard a thud which may have been a switch tripping in the electrical console unit which was downstairs. I am unable to determine the precise electrical fault that caused the fire 4 CIRCUMSTANCES OF THE DEATH The deceased died following a house fire in a property leased to them by the Council. The property contained two working smoke alarms but they were not activated by the fire, which started in a bedroom where the door was closed. 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 The first MATTERS OF CONCERN is as follows: I heard evidence during the inquest that two working smoke alarms were not activated by this fire which occurred in a residential Council owned property and which led to the deaths of two individuals. I heard that this may have happened because the fire was contained in a bedroom with the door closed. I heard evidence that Welsh Government legislation (Renting Homes (Wales) Act 2016 implemented by The Renting Homes (Fitness for Human Habitation) Wales Regulations 2022) only requires rented properties to be, inter alia, fitted with two hard wired smoke alarms and that separately, sprinkler systems are only mandated in new build properties or properties undergoing alterations (Domestic Fire Safety (Wales) Measure 2011). I heard that smoke alarms in hallways only safeguard communal areas and the means of escape in a fire and that they do not provide adequate protection to mitigate against the risk to life from fires which start in individual rooms, including bedrooms. I heard that sprinkler systems are expensive for Councils and landlords to fit but that they are very successful in controlling fires and reducing fatalities from fires in properties. I also heard that hard wired smoke alarms are less expensive to fit but would still be beyond the budget of a local Council with a significant property portfolio, which is the case here. I heard that smoke alarms provide the best protection against the risk to life posed by fire in domestic and other properties. I am concerned that only mandating two smoke alarms in rented accommodation means that there is a continuing risk to life from fire in such accommodation. The second MATTERS OF CONCERN is as follows: . The Chartered I heard that certain items within the bedroom where the fire started, including a console unit and electrical items, were removed before they could be fully inspected in situ by the Chartered Electrical Engineer instructed to investigate the cause of the fire. I am told that the items were removed by the Crime Scene Investigators from South Wales Police in circumstances where the Fire Service had exercised its power under section 45 of the Fire and Rescue Services Act 2004 and had commenced an investigation which was aimed at determining the point of origin, cause and behaviour of the fire at Electrical Engineer expert told me that he was unable to provide me with any assistance on the cause of the fire because the items had been removed from the scene and because he had only been able to view photographs. It was this Expert’s opinion that it would have been preferable if the items had remained in position at the property to enable him to inspect them in situ. I am concerned that items were removed from the scene before all inspections were completed and that this may have prevented me and indeed the Fire Service investigators from determining the cause of this fire. I am concerned either that there may not be a sufficiently robust protocol in place between South Wales Police and the Fire Service on preserving a scene to ensure a full investigation takes place and / or that if there is such a protocol it may not have been followed in this instance. If coroners and investigators are unable to determine the cause of a fire because the scene has not been preserved for as long as required to ensure a full in situ investigation by all instructed investigators, then this prevents lessons from being learnt about the cause of a fire which in turn means there is a continuing risk to life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17th January 2025. 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 both Interested Parties, namely, the family of the deceased and the City and County of Swansea. 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 form. 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 22 November 2024
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Prif Swyddog Tan | Chief Fire Officer
Gwasanaeth Tan ac Achub
Canolbarth a Gorllewin Cymru
3 Y Pencadlys, Heol Ltwyn Pisgwydd, Headquarters, Lime Grove Avenue,
{id and West Wales Ceerfyrddin, Sir Gar, SA3I1SP Carmarthen, Carmarthenshire, SA31 ISP
Fire and Rescue Service 7
Your Ref: =’
13" January 2025
Kirsten Heaven MA
HM Assistant Coroner for Swansea Neath Port Talbot
Coroner's Office
The Guildhall
Swansea
SA1 4PE
Dear Ms Heaven
Re: Inauest of Naemat & Muhammed Esmael - your iii
| write in reply to your letter of the 22"? November 2024 and attached Regulation 28 Report
to Prevent Future Deaths; my statutory response is as follows.
With regard to the first MATTER OF CONCERN.
Mid and West Wales Fire and Rescue Service support the notion that only mandating two
smoke alarms in [domestic] accommodation means that there is a continuing risk to life
from fire. The Service has previously raised this matter with the Welsh Government via the
All Wales Community Risk Reduction Committee, where the Service proposed increasing
smoke alarm coverage to the highest standard in all new build premises in Wales and
would equally support this enhancement of provision in rented accommodation. This will
require a change to existing legislation and/or Building Regulations guidance which can
only be undertaken by the Welsh Government.
Action Proposed: Mid & West Wales Fire and Rescue Service will support any proposals for
legislative enhancement by the Welsh Govemment in regard of fire alarm coverage in
domestic dwellings.
Rydym yn croesawu gohebiseth yn y Gymraeg a? Saesneg ‘We welcome correspondence in Welsh and English -
- byddwn yn ymateb yn gyfartal fr ddeu ac yn ateb yn eich we will respond equally to both and will reply in your
dewis laith heb oadi language of choice without delay.
Rydym yn croesawu galwedau yn y Gymraeg at Seesnag. ‘We weicome calls in Weish and English.
& 100% weal’ allgyichs | recycled
Prif Swyddog Tan | Chief Fire Officer
Gwasanaeth Tin ac Achub
‘ Canolbarth a Gorllewin Cymru
= . S Y Pencadlys, Heol Liwyn Pisgwydd, Headquarters, Lime Grove Avenue,
= Mid and West Wales Coerfyrddin, Sir G&r, SA311SP Carmarthen, Carmarthenshire, SA3I ISP
Fire and Rescue Service
EE 20.001: | ED erie gov
With regard to the second MATTER OF CONCERN.
In fire cases involving fatalities or suspected criminality, the Police are the lead agency with
primacy over the investigation. For incidents within its area, Mid & West Wales Fire and
Rescue Service will often support the Police with their investigation alongside Crime Scene
Investigators and forensic scientists commissioned by the Police, as in this case.
A decision to remove items for laboratory testing is undertaken by the Senior Police Officer
and any evidence subsequently seized is done under the authority offered by the Police
and Criminal Evidence Act (PACE).
Action Proposed: | do not propose to take any action in relation to this MATTER OF
CONCERN as primacy for scene management in cases such as this is a Police
responsibility.
Your sincerely
FC
Chief Fire Officer
Rydym yn croesawu gohebiseth yn y Gymrseg at Saesneg We welcome correspondence in Welsh and English -
- byddwn yn ymateb yn gyfertal fr ddau ac yn ateb yn wich we wil respore! equally to both and will reply in your = mei pcre emepiyt
dewis isith heb oedi language of choice without delay titans creetnseal cnt at
Rydym yn crossawu galwedeu yn y Gymraeg ar Soesneg. ‘We waicome calls in Welsh and English.
© 100% wedi'i silgyichu | recycled
Ysgrifennydd y Cabinet dros Lywodraeth Leol a Thai
Cabinet Secretary for Housing and Local Government
Eich cyf/Your ref
Ein cyf/Our ref
Kirsten Heaven
His Majesty’s Assistant Coroner
c/o
Coroners Case Manager
Dear Kirsten,
16 January 2025
Thank you for your letter and Regulation 28 Report in relation to the Inquests following the
sad deaths of Naemat and Muhammad Esmael.
I am responding in relation to the first Matter of Concern raised in your Report, regarding the
provision of smoke alarms within rented accommodation. The second Matter of Concern
relates to the possible removal by South Wales Police (SWP) of relevant items from the
scene of the fire, and to the working relationship between SWP and Mid and West Wales
Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and
MWWFRS over which the Welsh Government has no control; as such there is no action we
can take which would address this concern. However, I note your Report has also been
issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that
he will respond on that Matter.
Regarding the first Matter of Concern, Section 91 of the Renting Homes (Wales) Act 2016
(‘the 2016 Act’) places a general duty on landlords to ensure rented homes are fit for human
habitation. Section 94(1) of the 2016 Act also places a duty on the Welsh Ministers to
prescribe matters and circumstances to which regard must be had when determining
whether a home is fit for human habitation. This is further supplemented by Section 93(3),
which gives a power to the Welsh Ministers to impose requirements on landlords to prevent
any matters or circumstances arising that may cause a home to be unfit.
The duty to prescribe matters and circumstances to be considered in relation to fitness, as
well as the power to impose preventative requirements, are addressed in the Renting
Homes (Fitness for Human Habitation) (Wales) Regulations 2022 (‘the Regulations’). The
Regulations prescribe the same 29 hazards that local authorities use in conducting
assessments under the statutory Housing Health and Safety Rating System, which includes
the hazard of fire. The Regulations impose specific preventative requirements relating to
smoke alarms, carbon monoxide alarms and the inspection and testing of the electrical
installation. Regarding smoke alarms, landlords are required to ensure a hard-wired,
Canolfan Cyswllt Cyntaf / First Point of Contact Centre:
0300 0604400
Bae Caerdydd • Cardiff Bay
Caerdydd • Cardiff
CF99 1SN
Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd
gohebu yn Gymraeg yn arwain at oedi.
We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding
in Welsh will not lead to a delay in responding.
interconnected smoke alarm, that is in repair and in proper working order, is present on
each storey of a rented dwelling. If a landlord fails to comply with this requirement, the
dwelling is deemed to be unfit for human habitation and the contract-holder is not required
to pay rent during the period of non-compliance. Whilst this is the minimum statutory
requirement, non-statutory guidance accompanying the Regulations also states that,
depending on the size of the dwelling landlords, may consider it appropriate to ensure the
presence of more than one smoke alarm on each storey.
The current statutory requirements were the subject of a public consultation carried out in
2017. The consultation proposed a requirement for a smoke alarm in proper working order
to be present on each storey of the dwelling on which there is a room used wholly or partly
as living accommodation. As well as asking whether there should be a statutory duty on
landlords to fit smoke alarms, the consultation also sought views on the type of smoke
alarm to be installed and whether alarms should be interlinked. 91% or respondents to the
consultation agreed that requiring landlords to fit smoke alarms was a reasonable and
proportionate preventative measure. 53% of respondents considered there should be
further requirements specified in the Regulations, with the majority favouring a requirement
for hard-wired, inter-linked alarms. The final version of the Regulations made in January
2022 closely followed the findings of the consultation. For information, the requirement in
Wales in relation to having one hard-wired, inter-linked smoke alarm on each storey of a
rented dwelling, though not in every room, is similar to the requirements in England and
Scotland.
Although the Welsh Government keeps all legislation under review, the 2016 Act is
additionally subject to a three-year independent evaluation. This is considering all aspects
of the legislation and the Phase 1 report has indicated a good awareness of the
requirements in the Regulations, with landlords, agents and contract-holders all commenting
on the increased provision of smoke alarms and the other preventative measures. Phase 2
of the evaluation is currently nearing completion and Phase 3, which will report in 2025, will
consider the overall impact of the 2016 Act, including the Regulations. The findings of your
Regulation 28 report will be considered alongside the ongoing findings from the
independent evaluation and will inform a decision as to whether any changes to the current
regulations are required.
Yours sincerely
Ysgrifennydd y Cabinet dros Lywodraeth Leol a Thai
Cabinet Secretary for Housing and Local Government
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