Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0223, written 20 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Apr 2026 |
|---|---|
| Reference | 2026-0223 |
| Deceased | Paul Hutchinson |
| Coroner | Richard Furniss |
| Coroner area | West London |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
West London Coroner Service
25 Bagleys Lane, Fulham, London, SW6 2QA
Date: 19 April 2026
Case:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Local Government Association (
, Interim Chief Executive)
, Minister of Housing, Communities and Local Government
, Chair, National Fire Chiefs Council
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Interim Chief Executive, Care Quality Commission
CORONER
I am Richard Furniss, HM Assistant Coroner for West London
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
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INVESTIGATION and INQUEST
On 23 January 2025 I commenced an investigation into the death of Paul HUTCHINSON.
The investigation concluded at the end of the inquest on 20 April 2026. The conclusion of the
inquest was Accidental Death
The medical cause of death was
1a Burns
CIRCUMSTANCES OF THE DEATH
The Deceased died of burns in a fire in his Extra Care Sheltered Accommodation ('ECSA')
on 21 January 2025.
The building comprised 36 one- and two-bedroomed flats. The Deceased lived in a one-
bedroom flat. He had suffered a stroke in 2016 which caused him to have limited mobility
and speech, incontinence and cognitive difficulties. ECSA means that he lived independently
in self-contained accommodation but with managed on-site care and support on a 24-hour
basis.
In August 2024, a Person Centred Fire Risk Assessment ('PCFRA') determined the risk as
'high'. There were multiple burn marks on clothing , carpet and furninshings as a result of the
Deceased smoking, but no adequate control measures or mitigating measures were
recorded or taken, and there was no action to notify a local Fire Officer.
The Deceased set himself alight by smoking. His smoke detector activated at 1435 hours on
21 January 2025, but was silenced by a member of staff, as were multiple other detectors.
The first call to London Fire Brigade was 8 minutes after 1435 and the manager of the
accommodation did not contact LFB until 1450 hours.
The inquest heard evidence and submissions from London Fire Brigade.
5 CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to 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 report to you.
The MATTERS OF CONCERN are as follows.
1. The Regulatory Reform (Fire Safety) Order 2005 and the Fire Safety (Residential Evacuation
Plans) Regulations 2025 do not appear to apply to the individual flats in ECSA because they are
private dwellings. The concern is that there is no specific requirement for a PCFRA (or a
personal emergency evacuation through the PCFRA) with an agreed format and risk factors, a
requirement for emergency equipment and staff training and a timescale for regular reviews
(including where the individual circumstances of a person in care change). This concern may
apply to others in formal residential care.
2. Staff training is not standardised for ECSA (or sheltered accommodation more generally) and
may not include, for example, evacuation strategy, emergency evacuation plans, the use of
telecare/fire alarm system and fire suppression systems.
3. Fire Risk Assessments for premises providing ECSA and sheltered accommodation more
generally may not contemplate vulnerable residents as forming 'any group of persons
identified…as being especially at risk' (see article 9(7)(b) of the 2005 Regulations). Vulnerable
residents may be at special risk because of (for example) smoking or cooking practices and may
have a compromised ability to self-evacuate. The concern is that Fire Risk Assessments do not
take this into account.
ACTION SHOULD BE TAKEN
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In my opinion action should be taken to prevent future deaths and I believe you, the four
organisations listed above to whom this report is directed, have the power to take such
action.
YOUR RESPONSE
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You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16 June 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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
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Chief Executive, Housing 21
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.
20 April 2026
Signature
Richard Furniss HM Assistant Coroner for West London
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