Trevor Ridd

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

When a coroner sends a prevention of future deaths (PFD) report to a person or organisation, 
they must respond within 56 days. Recipients of a PFD report can apply to the coroner for an 
extension.  A response to a PFD report must detail the action taken or to be taken, whether in 
response to the report or otherwise, or it must explain why no action is proposed. 

The purpose of the response template below is to promote clarity, ensure that responses 
address the coroner’s concerns directly and transparently, and support consistency and good 
practice across organisations and sectors. It does not restrict how a person or organisation 
formulates their response; recipients remain responsible for determining what action is 
appropriate and for ensuring that their response accurately reflects the steps taken or planned. 

In accordance with the Chief Coroner’s PFD Publication Policy (2026) representations regarding 
publication of a response should be sent to the coroner. These representations should be made 
at the same time as the response is provided. The coroner will pass any representations 
received to the Chief Coroner for a decision 

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

(Please do not include any living persons’ names in this document, in accordance with the 
Chief Coroner’s PFD Publication Policy (2026)) 

 THIS RESPONSE IS BEING SENT TO: 

 HM Assistant Coroner, Paramdeep Bains, for Birmingham and Solihull in response to a 
‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the 
death of Trevor John Ridd that concluded on 9th March 2026.  

1 

 RESPONDENT 

 In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, 

, Managing Director, Birmingham City Council, provides this response within 56 

days (plus any extension granted) of the date of the Report to Prevent Future Deaths 

2 

 DATE OF RESPONSE 

 5th August 2026. 

 
  
  
 
  
 
 
  
  
 
  
 3 

 CONFIRMATION OF CORONER'S MATTERS OF CONCERN 

 The MATTERS OF CONCERN were identified in the report as follows: 

1.  It is not clear why the sprinkler system generated two signals (one 'fault' and one 'fire') 

within seconds of one another and what the procedure was for handling this. 

2.  It remains unclear as to why the individual operator treated both signals as being part 
of the same incident and failed to raise a 999 call; it is not clear how a fault notification 
works alongside a fire notification. 

3.  It is not clear what training or instruction individual operators receive in relation to how 
they are to deal with situations where two notification signals are received in quick 
succession. It is also unclear what information alerts (if any) are communicated to 
individual operators in respect of the property from which the signals are received. i.e. 
was it noted that the signals came from Mr Ridd’s property who was bed-bound and a 
known smoker with severe COPD where there had been a previous incident where he had 
singed his blanket from smoking in his bed?  

4.  The evidence at Inquest suggested that the two signals received were the wrong way 
around; however, it was not clear why this was and whether this has since been 
rectified. 

5.  There is no evidence of regular testing and maintenance of the sprinkler system. 

6.  It is not clear what individual operators have been briefed on post-incident regarding 
situations where two notification signals are received in quick succession from the 
same property. 

7.  It is not clear what communications have been issued to staff to reinforce the 

requirement to verify wording of any notifications received.  

 
 
 
 4 

 DETAILS OF ACTION TAKEN, how has the concern been addressed. 
(If no action is proposed please explain why here) 

 Please note that any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

 1. It is not clear why the sprinkler system generated two signals (one 'fault' and one 
'fire') within seconds of one another and what the procedure was for handling this. 

Careline Alarm Receiving Centre (ARC) receives both sprinkler system activation notifications 
and sprinkler system fault notifications from auto-dialler devices installed across our 
residential high-rise stock. These notifications are received via the CHUBB Skyresponse 
platform and are presented to call handling operators for action in accordance with 
established escalation procedures. 

Following investigation, it was identified that notifications can be generated in close 
succession for both a sprinkler activation and a maintenance/fault condition. In this incident, 
the CHUBB Skyresponse platform recorded a maintenance notification at 21:24:25, followed 
by a sprinkler activation notification at 21:24:46, a difference of 21 seconds. 

The CHUBB Skyresponse platform in use at the time had been operational for approximately 
one month and all Careline staff had received training from CHUBB on the operation of the 
new system, including the handling of notifications and calls received through the platform. 

Following the incident, all procedures relating to the management of duplicate notifications 
and multiple alerts from the same site have been reviewed and updated. The revised 
procedures now make explicit that each notification must be individually acknowledged, 
assessed, actioned and closed, regardless of whether another notification has already been 
received from the same property. 

2. It remains unclear as to why the individual operator treated both signals as being 
part of the same incident and failed to raise a 999 call; it is not clear how a fault 
notification works alongside a fire notification. 

The investigation established that the operator interpreted the second notification as relating 
to the maintenance/fault notification already being managed. Under the new CHUBB 
Skyresponse platform, operators are alerted when they are already handling a notification 
from the same auto-dialler device. As the system had only recently been introduced, this 
functionality was relatively unfamiliar to operators. 

The operator subsequently confirmed that the operator believed they were already dealing 
with the incident and therefore associated the activation notification with the existing 
maintenance notification. At the time, they contacted the repairs call centre to arrange 
attendance by an engineer and recorded the activation against the repairs reference already 
created. 

While this explanation provides context, the organisation accepts that a human error occurred 
in the handling of the escalation process and that a call should have been made to West 
Midlands Fire Service upon receipt of the activation signal. 

 
 Immediately following the incident, management issued written instructions to all operators 
reinforcing that duplicate notifications from the same site must not be assumed to relate to an 
existing incident and that each notification must be reviewed and actioned separately. This 
requirement was further reinforced through verbal briefings at the commencement of shifts 
and more recently through individual recorded discussions with all call handling operators. 

3. It is not clear what training or instruction individual operators receive in relation to 
how they are to deal with situations where two notification signals are received in 
quick succession. It is also unclear what information alerts (if any) are communicated 
to individual operators in respect of the property from which the signals are received 
i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and 
a known smoker with severe COPD where there had been a previous incident where he 
had singed his blanket from smoking in his bed?  

Prior to the implementation of the Care Unity system, all Careline operators received training 
delivered by CHUBB, the system provider. This training covered operation of the CHUBB 
Skyresponse platform, the management of alarm notifications, call handling requirements, 
escalation processes and operator actions in response to system-generated alerts. 

The CHUBB Skyresponse platform had only been operational for approximately one month at 
the time of the incident. Whilst training had been provided, the incident highlighted that further 
emphasis was required regarding the management of multiple notifications received from the 
same auto-dialler device within a short timeframe. In particular, operators required greater 
clarity that further notifications from the same site must not be assumed to relate to an 
incident already being managed and must instead be individually assessed and actioned. 

Following the incident, the organisation undertook an immediate review of operator training, 
guidance and procedures. This resulted in: 

•  Written clarification instructions were immediately issued to all operators regarding the 
handling of multiple notifications from the same site and that each notification must be 
reviewed and assessed individually. 

•  Electronic Pop-Up notifications created in the system as a reminder on every call to 
review all notifications even if they are received in close succession from the same 
property.  Each ‘Pop-Up’ has to be acknowledged & closed by operators before they 
can continue to handle that or any further calls. 

•  Managers provided verbal briefings to each operator as they commenced duty 

immediately after the incident. 

•  Further individual discussions have subsequently been undertaken and are ongoing 

and being formally recorded with each operator. 

•  Written procedures required as part of the TSA accreditation (ARC and technical install 
providers) have been reviewed and updated to provide the revised information and 
greater clarity regarding duplicate notifications and escalation requirements. 

•  Written confirmation is being obtained from all operators to confirm they have read, 

understood and will comply with the revised procedures. This assurance exercise will 
be completed by the end of August 2026. 

Operators receive the sprinkler system activation notifications and sprinkler system fault 
notifications from auto-dialler devices, the notifications do not include any details or alerts 
relating to tenants. 

 
 4. The evidence at Inquest suggested that the two signals received were the wrong way 
around; however, it was not clear why this was and whether this has since been 
rectified. 

Post-incident investigations undertaken by servicing and maintenance contractors identified 
that the CHUBB Skyresponse platform transmitter had been correctly configured and wired 
correctly.  There was not an error in installation configuration sending notifications the 
incorrect way around.  

5. There is no evidence of regular testing and maintenance of the sprinkler system. 

The sprinkler system at Hobbis House is subject to annual servicing and maintenance in 
accordance with BS 9251:2021, the British Standard Code of Practice for fire sprinkler 
systems in domestic and residential occupancies. 

The most recent annual service prior to the incident was completed on 23 January 2025. 
Although the service certificate recorded a fail outcome, this related to minor weeping from 
ground-floor valves. The identified issues did not affect the operational capability of the 
sprinkler system and remedial works were subsequently completed. 

The sprinkler system remained operational throughout the period and functioned as intended 
during the incident in January 2026, successfully activating and providing fire suppression. 

6. It is not clear what individual operators have been briefed on post-incident regarding 
situations where two notification signals are received in quick succession from the 
same property. 

The key message communicated to operators is that every alert received must be treated as 
a separate notification requiring individual assessment and action, regardless of whether 
another alert from the same property is already being managed. 

Immediately following the incident, line management issued written communications to all 
Control Centre staff highlighting the circumstances of the incident and reminding operators of 
their responsibilities when receiving multiple notifications from the same property. 

The communication specifically reinforced that: 

•  Each notification received by the system must be treated as a separate event requiring 

individual review and action. 

•  Operators must not assume that a subsequent notification relates solely to an incident 

that is already being handled. 

•  The wording and classification of each notification must be checked and verified before 

any action is taken. 

•  Escalation procedures must be followed in respect of every notification received. 
•  Activation notifications indicating a potential fire event must be dealt with in accordance 

with emergency response procedures. 

 
 
 
 In addition to the written communication, managers discussed the incident and the revised 
expectations verbally with operators as they attended for duty. Since that time, individual 
conversations have been undertaken with each operator to reinforce learning, discuss 
procedural requirements and ensure a consistent understanding of expectations. 

The organisation considers that these actions, together with the revision of written 
procedures, mandatory staff acknowledgement and ongoing management oversight, have 
significantly strengthened operator awareness and reduced the risk of a similar occurrence in 
the future. 

7. It is not clear what communications have been issued to staff to reinforce the 
requirement to verify wording of any notifications received. 

Following the incident, all staff were reminded of the importance of carefully reviewing the 
wording and classification of all notifications received through the CHUBB Skyresponse 
platform and ensuring that notifications are individually assessed rather than assumed to 
relate to an incident already in progress. 

This requirement has been incorporated into the revised written procedures and reinforced 
through management briefings, individual discussions and staff acknowledgement of 
procedural changes.  Written confirmation will be fully completed by end of August 2026. 

Additional Assurance Measures 

The Careline Alarm Receiving Centre is independently audited annually by the Technology 
Enabled Care Services Association (TSA) as part of its quality assurance and accreditation 
requirements. As part of the post-incident & annual review, procedures and operator guidance 
have been reviewed to strengthen compliance and ensure greater clarity in relation to the 
management of multiple notifications received from the same property. 

In addition to the procedural changes outlined above, the organisation recognises that 
effective operator training is fundamental to the safe operation of the Alarm Receiving Centre. 
Training requirements and operator competency arrangements have therefore been reviewed 
following this incident to ensure staff clearly understand the distinction between different 
alarm types, the need to assess each notification and the requirement to follow escalation 
procedures regardless of whether another notification from the same property is already being 
managed. This learning has been embedded through written procedures, management 
briefings, individual supervision and staff acknowledgement processes. 

The organisation believes these measures significantly reduce the likelihood of a similar 
occurrence and provide additional assurance regarding operator response, escalation 
processes and the management of sprinkler system notifications. 

 
 
  
  
  
 5 

 DETAILS OF FURTHER ACTION PROPOSED 

 Please note that any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

1.  Written confirmation is being obtained from all operators to confirm that they have read, 
understood and will comply with the revised procedures. This assurance exercise will be 
completed by the end of August 2026. 

2.  Further individual discussions with operators will continue through normal supervision and 
management arrangements to reinforce learning and maintain compliance with revised 
procedures. 

3.  Training requirements and operator competency arrangements will continue to be 
reviewed as part of the service's continuous improvement framework and TSA 
accreditation requirements. 

4.  Annual TSA quality assurance and accreditation audits will continue to provide external 

scrutiny of procedures, training arrangements and operational compliance. 

 SIGNATURE 

6 

Managing Director  

Birmingham City Council