Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0177, written 8 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Apr 2025 |
|---|---|
| Reference | 2025-0177 |
| Deceased | Ruth Pingree |
| Coroner | Darren Stewart |
| Coroner area | Suffolk |
| Category | Other related deaths · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 2 Housing, Communities and Local Government , Secretary of State for Home Department , Deputy Prime Minister & Secretary of State for 1 CORONER I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk 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 INVESTIGATION and INQUEST On 08 August 2022 I commenced an investigation touching the death of Ruth Ann PINGREE aged 42. The investigation concluded at the end of the inquest on 20 March 2025. The conclusion of the inquest was that: Narrative Conclusion - Ruth Ann PINGREE was described by her family as an amazing person. Someone who had a quality about them that drew you to her with her smile, her laugh, her heart, her vulnerability and her brilliant mind. She was a person who would make you feel loved and valued and appreciated. A one in a million. A person who was always there for her family and friends and utterly devoted to her children. On the 22nd July 2022, Mrs. Pingree, her husband and two children travelled from their home in Surrey to Suffolk where they had planned to spend time with friends holidaying in a caravan park. There were about seven families in total who travelled separately to the Happy Days Retro Vacation caravan site in Saxmundham, Suffolk. The party arrived during the evening of the 22nd July 2022. The Happy Days Retro Vacation caravan site was comprised of seven Airstream caravans arranged around various outbuildings which provided shower and toilet facilities. The caravans were made from an aluminium outer skin built on a wooden frame and steel chassis. Each caravan was named. The caravan occupied by the Pingree family was called ‘Betsy’. On the evening they arrived Mr. Pingree had briefly watched parts of an online video prepared by Happy Days Retro Vacations and which was intended to orientate guests to the caravan they would occupy and how particular aspects of the caravan operated. The video did not include a safety brief nor did the Pingree’s receive a safety brief on arrival at the Happy Days Retro Vacation site. The caravan ‘Betsy’ was fitted with a dual smoke and carbon monoxide detector and which was fixed to a wall in the kitchen area of the caravan. In addition, a fire blanket was affixed to a wall near the stove in the kitchen area and a small fire extinguisher was also located in the kitchen area. Having arrived during the evening of Friday the 22nd July 2022, the Pingree’s and their friends socialised outside near a fire pit before retiring for the evening. On Saturday the 23rd July 2022 the party enjoyed a day out travelling to Aldeburgh before returning later in the afternoon. As with the previous evening, the party socialised outside their caravans Ruth Ann PINGREE (01247–2022) Regulation 28 – After Inquest Document Template Updated 30/07/2021 during the evening with the last person retiring at approximately 23:30 hours. As had been the case the previous evening, a fire pit had been used and several of the adult members of the group had smoked cigarettes. Adult members of the group had also consumed alcohol. A security check of the site by the owner at around 00:30 hours on the morning of the 24th July 2022 revealed nothing untoward with no sign of a fire other than a few glowing embers in the fire pit. The weather at the time had been exceptionally dry with above average (hotter) temperatures for the time of year. It was also windy on the evening of the 23rd July 2022. At some point approximately between 00:30 hours and 04:30 hours on the 24th July 2022 a smouldering fire started outside the bathroom end of the caravan ‘Betsy’ which the Pingree’s were occupying. It is not possible to say whether this was started from an ember blowing out of the fire pit or from a discarded match or cigarette butt. The fire was not started due to an electrical fault. The fire developed over a period of time engaging the external structure of the caravan. The effect of this development meant that the external aluminium cladding of the caravan heated causing the door frame of the sole caravan door to become warped and made the door inoperable; in effect jammed shut. At some time between 04:00 and 04:30 hours Mr. Pingree was woken by his son who alerted him to the fact that there was a fire. At this point there was smoke in the caravan and the fire had started to engage the inside of the bathroom end where the children had been sleeping. The smoke detector fitted in the caravan had not activated and did not sound during the fire. Mr. Pingree sought to open the caravan door which had been left unlocked, but was unable to due to the effect of the fire on the door mechanism. A friend who had been staying in the adjacent caravan and who had become aware of the fire also tried to open the door to ‘Betsy’ unsuccessfully. Turning to the right and away from the door and facing his family who were in the kitchen area of the caravan, Mr. Pingree realised that quick action was required in order to escape the caravan. The fire was fully engaging the bathroom end of the caravan at this point and the entire space had quickly become full of acrid dark smoke. Mr. Pingree then used his body to force open the window above the sink in the kitchen area and climbed outside. He was followed by his two children. Mrs. Pingree had remained to assist the children in their escape. Her actions in doing so meant that the children were able to escape the burning caravan. Sadly Mrs. Pingree was not able to escape the caravan and shortly after the second child escaped, the caravan became engulfed in fire and smoke. Desperate efforts to extinguish the fire by those present were unsuccessful and it was not until the Fire Service arrived at 04:45 hours that the fire was finally extinguished. By this point Mrs. Pingree had sadly perished in the fire. Had the fire alarm functioned it is likely that this would have been before the Pingree’s son had raised the alarm. It is not possible however to say if this would have meant Mrs. Pingree would have escaped the caravan before being overcome by the fire fumes. A postmortem examination of Mrs. Pingree’s body established that her medical cause of death was due to the inhalation of fire fumes. Investigation of the cause of the fire established that the source of the fire was not due to an electrical fault, but rather either an ember blowing from a nearby fire pit or a discarded cigarette/match. This caused a smouldering fire to develop over a period of time outside the caravan and which then engulfed the caravan. Ruth Ann PINGREE (01247–2022) Regulation 28 – After Inquest Document Template Updated 30/07/2021 Ruth Ann PINGREE died as a result of the effects of a fire in a caravan she was holidaying in and which started due to accidental causes. The medical cause of death was confirmed as: 1a. Inhalation of fire fumes 4 CIRCUMSTANCES OF THE DEATH See Narrative Conclusion above 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you (and/or Ruth Ann PINGREE (01247–2022) Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 June 02, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (Husband) (via legal representatives) (Mother) (Sister) Happy Days Retro Vacations Ltd. (via legal representatives) Suffolk Fire and Rescue Service (via legal representatives) East Suffolk Council (via legal representatives) I have also sent it to The National Fire Chiefs Council who may find it useful or of interest. 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 Dated: 08/04/2025 Darren STEWART OBE HM Area Coroner for Suffolk Ruth Ann PINGREE (01247–2022) Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response 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.
Deputy Prime Minister and Secretary of State for
Housing, Communities & Local Government
2 Marsham Street
London
SW1P 4DF
Our reference:
21 May 2025
Darren Steward OBE
Area Coroner for Suffolk
HM Coroner's Court
Beacon House
White House Road
Ipswich
IP1 5PB
Dear Darren Steward OBE,
RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS - INQUEST INTO
THE DEATH OF RUTH ANN PINGREE
Thank you for your letter and investigative report dated 8 April 2025 into the tragic death of Mrs Ruth
Ann Pingree, which was made in accordance with Paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I want to start by offering my sincerest condolences to the family and friends of Mrs Pingree.
I understand that Mrs Pingree died in a caravan fire where the cause of the fire could not be
specified. I will go through the changes that have occurred since this tragic fire and what more is
being done to improve fire safety.
Modern fire safety legislation sets out high level objectives that must be achieved, both through
Building Regulations and the Regulatory Reform (Fire Safety) Order 2005 (FSO). The intention is to
allow flexibility in how legislative requirements are satisfied without being overly prescriptive.
Guidance
Under Article 50 of the FSO, the Secretary of State must ensure that appropriate guidance is made
available to Responsible Persons (RPs - those responsible for fire safety under the FSO) to
discharge their duties. Chief among which is to conduct a case specific fire risk assessment that
identifies the fire safety measures necessary and proportionate to the risk at that premises.
Since the tragic death of Mrs Pingree, the Government has enhanced the status of guidance issued
under Article 50 through Section 156 of the Building Safety Act, which now means that in any
proceedings on a breach of the FSO, the court can consider whether failure to comply with guidance
tends to establish if there was a contravention (with the converse point that compliance with
guidance may be relied upon to establish there was no contravention).
The relevant guidance at the time would have been the “Do you have paying guests?” guide which
was published in 2008 and therefore not long after the commencement of the FSO. As a result, it
may have been less definitive in its requirements, to adhere to the non-prescriptive nature of the
FSO. It covered a range of premises types from B&Bs to caravans, but in any case, did stress the
need for a fire risk assessment which considered the necessary fire safety measures for the
premises based on risk and complexity.
The Government published an update to this guide titled “Making your small paying guest
accommodation safe from fire” which superseded the older paying guests guide in March 2023 and
is available as a free download on GOV.UK. The new guide tends to be more stringent in relation to
the fire precautions it recommends.
Maintenance and written records
Your findings relating to the fire indicate that the smoke alarm did not operate. The new guide
recommends that for premises in scope, all smoke and heat alarms should be mains powered, with
a tamper-proof power supply consisting of a battery, which should improve their reliability. Where
these smoke and heat alarms are not already present at the time of the fire risk assessment, the
guide recommends that long-life, tamper-proof batteries may be acceptable as a short-term
measure of 2-3 years until mains-powered devices are installed. The guide also makes clear the
importance of replacing smoke and heat alarms periodically, with a suggested typical lifespan of 10
years.
The guide recommends that smoke and heat alarms should be tested monthly. Additionally, this
routine test should be done on each change of occupancy of premises in which staff or owners are
not present such as the case with caravans.
The FSO does not have a requirement for keeping records of testing and maintenance, but the new
guide recommends this is done through a logbook or electronic record. It also highlights a best
practice maintenance and testing checklist to make sure items and equipment are checked.
Since the fire, the Government has also changed the requirements on fire risk assessments where
they all now need to be recorded, and it is no longer limited to just ‘significant’ findings but all findings.
Action in case of emergency
The new guidance explains that suitable fire procedures must be developed to ensure that staff,
guests and visitors are made aware of what action they need to take in the event of a fire with
examples of the types of fire safety signs/notices which should be provided.
Fire risk assessment
In your letter, you raise concerns about a lack of specific guidance on how to conduct a fire risk
assessment and what needs to be covered. The new guide mentioned above provides a template
for this which should encourage the RP to consider every fire safety measure which might be
required.
Bespoke guidance
The new guide does not specifically cater for caravans solely and remains a guide that could apply
to a broad range of premises that offer short term holiday lets, as such it caveats where some
measures would not be appropriate for certain premises types like fire doors in caravans. We are
aware that an interested grouping of caravan operators has recently commissioned an independent
fire safety consultant to draft bespoke guidance for caravans which is something that we support.
We understand that it will be very similar to the guide issued by Government but will have specific
measures for holiday caravan and sites. We have asked to be kept informed of progress and will
input where necessary to make sure this can consider and address the relevant findings from your
letter.
Taken together, these measures should have improved fire safety for guests such as Mrs Pingree
going forward.
I would like to thank you for bringing this matter to my attention and, once again, I wish to express
my sincere condolences to Mrs Pingree’s family and friends.
Yours sincerely,
Deputy Prime Minister and Secretary of State for Housing, Communities & Local Government
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