Prevention of Future Deaths reports · 2026
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 report | 19 Feb 2026 |
|---|---|
| Reference | 2026-0102 |
| Deceased | Jacqueline Joseph |
| Coroner | Bina Patel |
| Coroner area | Bedfordshire and Luton |
| Category | Other 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 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
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.
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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