Coroners Court: The Old Fire Station Kendal Coroner’s Regulation 28 Letter Impact’s Response

We note the matters of concern raised in the Coroners Regulation 28 Letter. We have carried out a full review of our approach to fire precaution and evacuation. This response has been prepared in conjunction with of Total Fire Services Ltd and Rowena Jackson, independent Health and Safety Consultant1. It is broken down into 3 key sections
1. What we currently do,
2. Our review of the incident and
3. What we intend to do following the Inquest verdict.

It is perhaps worth stating at the beginning that Impact’s buildings and Fire Safety procedures worked to legislation, good practice and as designed. Fire alarms, etc., worked as they should and the means of exit worked as they should. There is a question over the tightness of fire seals around the designated exit door from the flat but this is normal in the event of a fire, albeit making the door more difficult to open. The Coroner’s question seems to be entirely around whether anything can and should be done to the windows in this flat and other flats to make it easier for an occupant to escape in case of fire

Mike Muir Chief Executive Impact Housing February 2017

1 Darren Baird DMS, MIFireE, MIFSM Total Fire Services Ltd Rowena Jackson BSc (Hons) CMIOSH

1. WHAT WE CURRENTLY DO

In both our general needs and our supported housing, we work to 4 linked considerations, which we will explore in detail, below:
i. What does a risk based approach mean?
ii. What are the design requirements and other constraints of the building?
iii. What are the characteristics and needs of the tenants in each building?
iv. What are the management arrangements in place to support those tenants?

i How impact operates a risk based approach For all of our properties, in respect of fire and other risks and in respect of our various systems and management practices, we consider 3 variables: the use of the building, the needs of the tenants that we are housing and the sort and level of support that we provide. Our approach to a modern house with a general needs tenant is very different from an old block of flats with vulnerable tenants and a package of support. In all cases, around Fire Safety, we rely on our own systems and training backed up by specialist fire safety advice and inspection from Total Fire Services Ltd. (Fire Risk Assessments, consultancy and Reports) and other health and safety advice from

(Health & Safety Consultant).

We operate to current Building Regulations and all other relevant Legislation, Guidance and Good Practice. In respect of schemes like the Old Fire Station, specifically,  we give guidance to tenants on what to do to prevent fire and what to do if it breaks out  we carry out regular Fire Drills (ie full practice evacuations)  we have a current Fire Risk Assessment  we regularly inspect tenants’ flats  we work to the Police Secure by Design

We understand that the Fire Officer’s statement to the Inquest confirmed that Impact had done everything correctly within current fire safety legislation. The designated fire exit route (the flat entrance door) worked as intended. The fire was contained within the flat. The other residents were evacuated without injury.

ii The Design and other Constraints of this Building For the last 30 years, Building Regulations have specified certain windows in residential properties to be “escape windows” which are designed to be easily opened from the inside in an emergency. Typically, escape windows will have one full opening light, that opens sideways, that is easy to open and, where lockable, is easy to unlock from the inside in an emergency. Such windows are required where there is no other satisfactory means of escape- typically, bedrooms at the end of a corridor on the first floor of a family house. Blocks of flats and 3 storey houses will usually have a good means of escape through protected exit routes. Escape windows are not considered as a secondary means of escape above the first storey (4.5m) for safety reasons.

iii The Tenants of this Building As the Fire Officer indicated at the Inquest, escape windows are not recommended in a property such as the Old Fire Station, where the designated means of escape is adequate. Indeed, in all of our schemes for vulnerable tenants, for security reasons and personal safety, we normally ensure that individuals cannot exit from windows. We would in general discourage tenants from opening a restrictor window that has been placed there for their personal safety and security.

iv Management Support at this Building We have a risk based approach to our relationship with our tenants. In schemes such as the Old Fire Station, we have an Evacuation policy and have practice fire drills for residents. We also have specific clauses in our Tenancy Agreement to cover the current circumstances which caused the fire:
23.1 You must not store in your home or communal areas, quantities of inflammable explosive or potentially dangerous materials or gases other than those which may be reasonably required for domestic use; nor store any petrol driven vehicle or appliance within the dwelling or in communal areas, other than designated parking areas or leave bicycles anywhere that they could cause an obstruction or fire hazard.
23.2 You must not hoard items in your home if that may be a fire or health risk or prevent access to your property.

We design buildings for specific uses, we house specific groups of tenants with specific needs and we provide competent staffing support to meet those needs. We have a number of projects for young people with varying combinations of building design, tenants’ needs and tenant support. For our young people, we provide a safe and secure environment, we provide a balance of support and independence, so we assist them to learn life skills, engage with specialist agencies to move them into training or employment and, in due course, assist them to move on to independent living.

Thus, we allow our tenants to have visitors, we have tenancy rules, we have room inspections, but we do not have curfews, we do not have 24 hour on site staffing support. This is a particular model that we have developed successfully over many years that balances support and independence.

2. OUR REVIEW OF THE INCIDENT FOLLOWING THE INQUEST

Following review of the evidence supplied at the Inquest, discussions with our own staff, with the tenant concerned, with the Fire Investigation Officer who attended the scene, with our own Fire and Health & Safety consultants (see above) and from looking again at our records, including CCTV coverage, and at our procedures, we had come to the view that the incident was a tragic accident involving two young men who were carrying out an activity that was not allowed and which entailed significant risk to themselves and others. Impact followed all of the relevant legislation and good practice and its own internal procedures. However, in our current, further, consideration of the Incident, we have considered our existing position, viz
1. The fire safety arrangements and procedures in place worked as they were designed2
2. There was nothing further that a reasonable landlord could be expected within existing good practice to have done to foresee and prevent
3. The incident and sequence of events were of a unique and unusual nature (the consequences of a rapid flash over from ignited petrol vapours) that residential properties cannot reasonably be foreseen and designed to protect against
4. Changing the opening arrangement of those windows might have made a significant difference to the outcome. However, subject to what alternative arrangements we made, it might also have created a number of other problems and risks (say, delay in the tenant exiting, or distraction from, the correct exit route). The same issues would apply to our other properties more generally and the redesign of their windows

Impact Housing has been operating as a housing charity for 42 years. Throughout that time, with a very good safety track record, we have provided family and general needs housing and supported housing to many thousands of Cumbrian households. One of our key specialisms has been in the provision of housing and support to vulnerable people, including young people from the age of 16 upwards. We hope that, through constantly reviewing our procedures and learning from incidents such as this, we constantly refine our approach to those very important roles.

In this document, we set out some of the proposals that we will implement and the learning that we are now putting in place following the Incident.

2 The compelling evidence that has led to us to this view is the CCTV footage “OFS Fire Lobby CCTV Footage”, a copy of which was presented to the Inquest. It shows our tenant leaving the flat and, indeed, returning to it. It shows that the smoke and blast were contained within the flat and the designated exit route had worked as designed..

3. WHAT WE INTEND TO DO FOLLOWING THE INQUEST

1. Our Tenancy and Licence Agreements cover such forbidden activities. We will ensure that younger residents in particular are more regularly reminded of the risks of carrying out forbidden activities in our buildings, with further explanation as to why these are forbidden activities

2. Whilst the likelihood of this incident happening again is extremely low, we will redouble our efforts to remind our tenants of the risks from forbidden appliances

3. We have a number of slightly different housing and support arrangements, for which we have slightly differing procedures (eg. fully supported schemes, low support schemes, newly designed schemes, schemes where there is a change of use, properties where there is a change of tenant). Whilst there is nothing that we will do significantly differently in the Old Fire Station (other than works to the windows; see below), there is a potential weakness where a situation changes- in particular where the use of the building changes (say, a more vulnerable tenant) and where we are considering changing a building component (say, replacing an existing window). We will bring in new procedures to ensure that any new risks introduced as a result of these changes of circumstance are reduced so far as is reasonably practicable

4. Whilst the fire evacuation arrangements worked as planned, we will reiterate to all of our staff the need to periodically remind our tenants of the procedures in place for their specific circumstances

5. With our 2 lead consultants, we will carry out a further, high level, review of our higher risk properties to see if there is any further learning

6. In this property and across our wider stock, we will look again at the arrangements for window design, as set out in greater detail, below

Impact Approach to Window Design and Window Restrictors The main reason for fitting restrictors is to reduce the risk of falling from height, although we would also generally fit restrictors to ground floor windows as both an additional security measure and/or for outward opening windows to reduce the risk of a window being opened and hitting a passer-by. The type of restrictor fitted is generally the hook type which is fitted to the opening sash and hooks over a pin fitted to the frame or a restrictor as an integral part of the hinge. In the case of the Old Fire Station, windows consist of small panes, with an opening lower light which has a hinge half way down both sides allowing it to pivot from vertical to horizontal on this central point; this means that, when open, the bottom third (roughly) of the window opening is fully accessible. See below for details of current restrictors.

We have several problems to address in deciding our general course of action:

1. Whilst it is relatively easy to fit a restrictor which is easy for the tenant to override, it is more difficult for a restrictor to be overridden by a visitor who does not know the property and who is in distress.
2. Not all properties can have their restrictors removed (eg on upper floors where the risk from a fall would be high or where Building Regulations do not allow it)
3. Not all windows can be easily exited because of their design (eg top opening lights or where there are small fixed panes in a listed building)
4. Not all tenants could be allowed to have windows that are easy to exit (eg those with dementia or otherwise impaired judgement)
5. We do not want to do anything to confuse the tenant in what is the designated and prfered exit route in case of an emergency
6. The cost of replacement can be prohibitely high

In this particular flat (Old Fire Station, ground floor), our proposal is as follows:
a. There are simple “cable restrictors” on the windows (see diagram). We will remove them. This will allow exit, albeit with some slight difficulty. A work order has been issued and the works will be completed by Friday 17 February

More generally, we have now considered the Coroner’s recommendations and, below, set out the approach that we will be taking across the whole of our stock (including The Old Fire Station). This approach builds on the risk based approach that we have across all of our responsibilities.

New Development Properties Controls Action Newbuild schemes that have not yet reached Building Building Regulation approval is in all cases required for the Windows installed in schemes from now on (see definition)

Contract Signed Stage (c30 new flats/houses per annum) works, and therefore the windows installed would have to comply and be approved by Building Control (and also on new build the third party warranty provided, such as LABC, Premier Guarantee etc) also up to relatively recently the most schemes would be Govt funded and have to meet the “Housing Quality Standards”. All of these requirements put differing constraints on the exact nature of any windows and opening mechanisms.

will normally be UPVC outward opening side hung casement window, with easy clean hinges (to enable the window to be cleaned from the inside) with lockable handle and a restrictor which can be easily overridden in an embergency. In specific cases (eg general needs ground floor properties) it may be possible to design without a restrictor

Planning restrictions or specific building limitations, mean that a variety of windows will continue to be installed, such as top hung windows, timber, tilt and turn. We will design these windows without restrictors on the ground floor and on upper floors with restrictors that are easy to override in an emergency. Within those same restrictions, we will design the windows so that they can be exited in an emergency

Properties bought from a private developer (6 units in 2017 and typically per annum)

Restrictors are generally not fitted. We have little control over the specific design of these properties as they are bought “off the shelf” on a one- off basis. As above, subject to constraints set out here Refurbished or remodelled properties that have not yet reached Building Contract Signed Stage or where Work Orders have not yet been issued (22 units in 2017 and typically per annum) If Building Control permission is required or properties are listed, then windows and restrictors will meet regulatory requirements.

New windows, as above, from now on

From now on, in such schemes, where we are not replacing windows, existing windows with restrictors without an override will be adapted or replaced to achieve as near as possible the approach set out above

Existing Properties Properties Action Residential properties with staff on site. Vulnerable tenants, different building All properties to be surveyed by end March 2017 to identify styles of windows and window

types and sizes. (64 properties, with varying number of flats or bedspaces) locks fitted. Works to remove fixed restrictors and replace with restrictors which can be over- ridden will commence in April 2017 and complete by end-March 2018.. Within that timescale, the order will be based on the level of risk to residents, phasing and availability of funding. Properties as they become void. General needs tenants. (250 – 300 per annum) As “Refurbished or remodelled properties “ above

All other general needs properties. 2,300 properties To be assessed through general stock condition surveys, repairs or maintenance. As properties become vacant, I.e. (“Properties as they become void”) they will be treated as for “Refurbished or remodelled properties “above. We have a 5yr rolling programme of inspection of all properties and we will include the removal or replacement of restrictors in those properties as they come up for inspection.

Exceptions
1. On inspection, if there are any properties where none of the above actions can be considered to ground floor windows, we will consider, on a case by case basis, provision of a break-glass hammer to be placed alongside that window. In such properties, if they exist, we will also conside on an individual property-by-property risk basis, a similar provision on first floor windows. This is not a satisfactory solution, because of the risk from broken glass and our inability to have assurance that the hammer remains in place.
2. We will continue to restrict ease of window exit for all properties with tenants in upper floor flats with dementia or otherwise impaired judgement, where the risk to them of trying to jump from a window would be too great