Prevention of Future Deaths reports · 2026

Jacqueline Joseph

Regulation 28 report to prevent future deaths, reference 2026-0102, written 19 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Feb 2026
Reference2026-0102
DeceasedJacqueline Joseph
CoronerBina Patel
Coroner areaBedfordshire and Luton
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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  Squared (Luton Community Housing Ltd) Unit 2B Enterprise Way Bramingham 

Business Centre Luton 

1  CORONER 

I am Bina PATEL, Area Coroner for the coroner area of Bedfordshire and Luton Coroner 
Service 

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 16 June 2025, I commenced an investigation into the death of Jacqueline JOSEPH aged 
60, who died on the 15 June 2025.  The investigation concluded at the end of the inquest 
on 13 November 2025.  

The medical cause of death was:  

1a Direct Thermal Injury 

1b Fire Exposure 

The conclusion of the inquest was: Accident.  

4  CIRCUMSTANCES OF THE DEATH 

Jacqueline JOSEPH occupies 2 Ellenhall Close, Luton, Bedfordshire, a housing association 
property. She was a known smoker, had a stroke approximately 10 years ago and limited 
mobility, as a result she had care and support needs. She was supported by carers who 
visited her four times a day. The premises had one battery-operated smoke alarm positioned 
on a vertical wall on the first-floor landing and one battery-operated smoke alarm position 
on top of the cooker grill in the ground floor kitchen. No careline provision was installed at 
the premises. Bedfordshire Fire Rescue Service had never visited the premises before the 
999 call on the 15 June 2025 as they had never received a Home Fire Safety Visit Referral 
from authorities or family.  

On the 15 June 2025, she was found in an armchair of the living room on the ground floor of 
the premises. She was confirmed deceased on this day having been discovered seated in the 
armchair subjected to flame and heat which had sustained itself from her lap, unable to 
extinguish the fire or self-rescue, Jacqueline Joseph succumbed to the fire and heat. Her 
daughter immediately alerted Bedfordshire Fire Service having observed her mother on fire 
via a camera (CCTV) installed in her lounge by the family, and their response time was 
prompt. In the fire investigator’s opinion, aside from pre-prepared preventative measures 
such as a fire suppression system, nothing further could have been done to save Jacqueline 
Joseph on 15th June 2025 once the fire had fully developed. Luton Safeguarding Adults 
Board (LSAB) since the date of this incident are undertaking work with partner agencies to 
ensure residents who are home, immobile or housebound with specific support needs have 
received referrals for a Home Fire Safety Visit where applicable. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
   
 
 
 
 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 premises is a housing association property and Squared (Luton Community Housing Ltd) 
is the organisation responsible for this property and various other housing association 
properties and the evidence heard at the inquest was that the premises had two incorrectly 
installed battery-operated smoke alarms.   

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or 
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 April 16, 2026.  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 the following Interested 
Persons 

Jacqueline Joseph’s Family 
Luton Borough Council 
Blue Bird Care  

I have also sent it to 

Bedfordshire Fire Service 
Luton Safeguarding Adults Board  

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it useful or 
of interest. 

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. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9 

Dated: 19 February 2026 

Bina PATEL 
Area Coroner for 
Bedfordshire and Luton Coroner Service 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Squared (PDF)
Sent via email  

15th April 2026  

Bina Patel  
Bedfordshire and Luton Coroner Service 
Central Bedfordshire Council   
The Court House  
Woburn Street 
Ampthill 
MK45 2HX  

Dear Ms Patel 

RE: Response to Regulation 28 Report Jacqueline Joseph   

Thank you for your Regulation 28 Report issued following the inquest into the tragic death of 
Jacqueline Joseph. We extend our sincere condolences to the family and all those affected. 
We write with the full authority of Squared’s Board. 

We recognise and acknowledge the seriousness of the concerns you have raised. Customer 
safety is Squared’s most important priority. We are committed to ensuring that all reasonable 
steps are taken to promote fire safety in the homes we let.  

For completeness, please note that liability is not accepted in this particular case. However, 
this will not affect our determination to learn from this tragedy. 

Our approach to vulnerable customers 

Squared aims to identify and monitor the needs of vulnerable customers on an ongoing basis 
and particularly at key stages of their tenancy journey. This includes during tenancy sign‑up 
and  through  tenancy  audit  inspections.  In  addition,  any  further  reports  or  concerns  arising 
from  contractors  (internal  and  external)  during  compliance  visits  or  routine  maintenance 
works, are fed back to the Homes Team to address where appropriate. 

If adaptations or any identified risks are highlighted, we work with Luton Borough Council and 
the  assigned  Occupational  Therapist  to  best  action  the  customer’s  need.  Frontline  team 
members  are trained to recognise and  report  all  concerns,  ensuring timely  referrals to the 
Homes Team or escalation to the Safeguarding Lead.  

With  this  in  mind,  we  maintain  strong  working  relationships  with  social  services  and  other 
partner agencies. This means that we can signpost customers to appropriate external support 
to aid them in seeking the assistance they need. We are committed to keeping these practices 
under regular review to ensure that no safeguarding opportunity is missed. 

squared.org.uk 

01582 391 053 

Squared, Bramingham 
Business Centre, Unit B2, 
Enterprise Way, Luton, 
Bedfordshire, LU3 4BU 

            Housing | Homes with Support               

           Landlord Services | Cleaning and Gardening  

Registered under the Co-operative and Community Benefit Societies Act 

2014  with charitable status: Registration No 19688R. A member of the 

National  Housing Federation Homes & Community Agency: 

Registration No. L1518. 

Luton Community Housing Limited trading as Squared. 

 
 
 
 
 
 
                                 
 
                              
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fire safety 

Policies have, for some time, been in place to ensure that homes let by Squared are to a high 
standard. Whilst these policies pre-dated the tragic death of Ms Joseph, it was only right for 
us to have reassessed them, in light of the tragedy. We detail this further below. 

Squared’s  approach  to  fire  safety  is  not  limited  to  its  strict  legal  obligations.  The  late  Ms 
(”the Property”) began in November 
Joseph’s tenancy of 
1996. Whilst this placed the tenancy outside of the scope of the Smoke and Carbon Monoxide 
Alarm (England) Regulations 2015, smoke alarms were nonetheless fitted to each storey of 
the property as though those regulations had applied. 

We were very concerned to note your reference to evidence of “incorrectly installed battery-
operated  smoke  alarms”.    As  detailed  further  in  this  letter,  Squared  will  work  with  both 
Bedfordshire Fire and Rescue Service and Luton Borough Council to ensure that any defect 
or potential defect is fully understood, rectified and learned from. 

Review 

As you would expect, an internal review has taken place following the receipt of your report. 

This included an examination of our processes to include strengthening/enhancing: 

•  Our tenancy audit checklist to ensure that smoke and carbon monoxide alarms are tested 

and recorded appropriately. 

•  Our  data  held  on  customers  with  vulnerabilities  to  ensure  it  is  accurate,  current  and 

supports fire safety risk management.  

•  Our gas safety certification procedures to provide increased oversight. 
•  Our  communication  practices  relating  to  smoke  and  carbon  monoxide  (CO)  alarm 

compliance.  

Squared remains committed to ensuring that all properties meet or exceed statutory safety 
requirements  and  that  our  customers  are  properly  supported  to  understand  and  fulfil  their 
responsibilities regarding alarm testing and reporting. 

Actions Taken or already in place  

Measures are being implemented across our services to ensure best practice. 

Actions Taken or already in place  

Current Status  

We continue to test smoke and CO alarms during voids 
(periods when homes are unoccupied), annual gas safety 
checks and during tenancy audits. Repairs or replacements 
are carried out as necessary. 

For the maximum avoidance of any doubt, a comprehensive 
smoke and CO alarm audit has been completed across all 
homes let by Squared (whether we own the freehold or not) to 
confirm that all devices are fitted in accordance with Smoke 
and Carbon Monoxide Alarm (Amendment) Regulations 2022 
and are in good working order.  All issues identified are being 
surveyed and any confirmed failures are being remedied 
without delay through emergency repairs. 

In place and ongoing  

Audit completed  

Surveys in progress with target 
completion date of 30th May 
2026 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We have written to all customers to reinforce the importance 
of smoke and carbon monoxide alarm safety.   

Customer communication 
completed 10th March 2026 

To be repeated 6 monthly   

Review 1st May 2026   

Start date 13th April 2026 

Target date for completion 12th 
June 2026  

Completed 3rd March 2026 and 
ongoing  

Completed 16th March 2026  

To be repeated quarterly  

Contacted Beds Fire and 
Rescue Service 9th March 2026  

Contacted Luton Borough 
Council 11th March 2026  

Start date 13th April 2026  

Target date for completion 17th 
July 2026 and then ongoing  

While customers are ordinarily encouraged to test alarms, 
report faults and replace batteries (where this is their 
responsibility), we recognise that some customers will require 
practical support or adjusted arrangements, and we will be 
reviewing how this is identified and provided consistently.  

Tenancy audits prioritised for known vulnerable, relevant 
customers to ensure data is accurate and up to date.   

We have enhanced our customer sign-up process so that, not 
only are alarms tested at the start of the tenancy, but the 
customers are asked to confirm that they are satisfied they 
are in working order. 

We have circulated a focused bulletin to frontline team 
members, reiterating their critical responsibility in maintaining 
customer safety by ensuring smoke, heat, and CO alarms are 
correctly managed. 

We contacted the Beds Fire and Rescue Service to request 
their feedback on our draft response, ensuring it is accurate, 
comprehensive, and that no fire‑safety considerations have 
been overlooked. They directed us to engage with Luton 
Borough Council’s Private Sector Housing team, which we 
have done, and we are now awaiting their response. 

We will proactively implement person centred fire risk 
assessments and put Personal Emergency Evacuation Plans 
(PEEPs) in place for customers whose mobility, disability, 
health or support needs may affect fire safety or their ability to 
evacuate safely. We will identify customers with needs that 
may impact fire safety or evacuation to carry out a person 
centred fire risk assessments and PEEPs where appropriate, 
prioritising those with known and existing vulnerabilities. In 
parallel, we will review how customers who are housebound, 
immobile, or otherwise have relevant support needs are 
identified, and how they are considered for referral to partner 
agencies for additional fire safety support where appropriate. 

Actions Proposed and Ongoing Improvements 

To further strengthen our approach and reduce future risk, we are implementing the following 
measures: 

Actions Proposed  

Status  

In addition to our statutory obligations, we have 
implemented a planned rolling programme to replace 
smoke, heat and carbon monoxide alarms upon reaching 
the manufacturer-recommended 10-year lifespan. This 

Start date 23rd April 2026 and 
rolling  

3 

 
 
 
 
 
 
 
 approach ensures that all alarms remain compliant with the 
LD2 standard.   

For properties where we do not hold the freehold (leased 
properties), we will undertake surveys to ensure that all 
alarms are compliant and are replaced as they approach 
the end of their service life. 

Start date 20th April 2026 

Target completion date 29th May 
2026   

Future monthly Leadership and quarterly Board reports will 
now include smoke, heat and CO alarms updates. 

Leadership Team Meeting 30th 
April 2026 and ongoing   

We plan to include smoke, heat, and CO alarm 
replacement updates as an agenda item at our next 
Customer Engagement Group meeting, to ensure ongoing 
customer involvement and feedback. 

Consideration to be given to promoting smoke-free homes 
as part of our wider approach to improving fire safety and 
customer wellbeing with our Customer Engagement Group 

To support robust implementation and provide independent 
assurance, we are considering commissioning an internal 
audit or other independent review of our fire safety controls. 

Board meeting 27th May 2026 and 
ongoing  

Customer Engagement Group 
meeting 28th April 2026   

Customer Engagement Group 
meeting 28th April 2026  

Leadership meeting 30th April 
2026  

Scoping and timings to be 
confirmed by 17th July 2026  

These  actions  are  designed  to strengthen  our  compliance framework,  maximise oversight, 
and ensure that both team members and tenants remain fully aware of their responsibilities. 

We repeat that Squared takes the matters raised in your report extremely seriously. We are 
committed  to  learning  all  we  can from  this  incident.  The actions  outlined above  reflect  our 
determination  to  maximise  safety  standards,  our  communication  with  customers,  and  the 
extent to which we work collaboratively with partner agencies. 

Should you require any further information or clarification, we will be pleased to provide it. 

Yours sincerely 

Board Chair 

4

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