Dear Mr Cooper,

18 December 2023

Frederick Powell deceased, 20 St Martin’s Close, Blyton

This response is provided by Acis Group Limited (‘AGL’) in relation to the Regulation 28: Report to Prevent Future Deaths dated 24 October 2023 received from HM Assistant Coroner for Lincolnshire because of Frederick Powell deceased’s death on the 6 September 2023, at the property known as 20 St Martin’s Close, Blyton (‘the property’), which is a general needs bungalow.

Frederick Powell deceased (‘the resident’) occupied the property as a tenant of AGL under an Assured Tenancy that commenced on 11 September 2006. The resident was 93 years of age at his death and had been a tenant with AGL since 1986, having occupied an alternative property also let by AGL, before his move into the property in 2006.

On 6 September 2023 the resident was the subject of a tragic incident which occurred when he fell through an internal door which contained non-toughened glazing, resulting in his subsequent death from his injuries.

AGL was advised by Lincolnshire Police that the resident had been discharged from hospital on 25 August 2023 where he had been receiving treatment for Plural Effusion query Mesothelioma and that the resident had various other ailments including frailty and dementia, the result of which was that the resident was reported to have been unstable on his feet. The resident had been sleeping in his recliner chair, which was situated in the living room of the property, as he had been awaiting a specialist bed to be delivered. AGL had not been informed of the resident’s discharge from hospital and so at the time of the resident’s death were unaware of the circumstances.

The Matter of Concern identified within the Coroner’s Report was:

‘’Although it is not suggested current building regulations were breached the Inquest was told many more properties in your stock retained internal glass doors. Is it time for a review to reconsider replacement?’’

Prior to receiving the Regulation 28 Report To Prevent Future Deaths from the Coroner, AGL had already been working proactively to address the concern later raised by the Coroner in relation to internal glazing on their housing stock, for example in 2020 AGL’s Lettable Standard (the specification to which an empty property must meet prior to being re-let) was revised and included specific provision to replace or encapsulate single glazing prior to the re-letting of an empty property.

(Cont’d)

In relation to the specific property, it was constructed in 1967 and met all relevant Building Regulations at that time of construction and build. The decorative glass door and panel were original features of the property, with the requirement to provide toughened safety glazing only coming in with subsequent changes to the Building Regulations. It is important to also note that any changes to Building Regulations do not apply retrospectively.

The property also met the Regulator of Social Housing’s Decent Homes Standard, and AGL was not on notice of any defect relating to its repair and maintenance obligations, either in general or specifically in respect of the glazed door. Whilst AGL was aware of the presence of this type of glazing in some of its properties, the inherent risk was considered to be low, and therefore AGL initiated a policy to address it over time, as and when those properties with that type of glazing became empty, thus being picked up through the Lettable Standard.

Following the tragic circumstances of the resident’s death, AGL has publicly expressed its condolences to the resident’s family and friends. AGL also immediately undertook an exercise to identify any other properties within AGL’s stock that might also incorporate internal single glazed doors and/or panels and an action plan has been set out to address those properties based on information held by AGL around the tenant’s age and health needs (where known) in order to prioritise a proactive programme of improvements based on the risk-based profile of the tenants.

AGL has started to contact those customers, by priority banding. As part of this process, AGL is offering information, advice and guidance to its tenants, and is also discussing all possible actions to replace or encapsulate any identified glazing. AGL expects that the proactive contact with its tenants will be concluded by the end of March 2024, albeit that any resultant remedial actions will take longer, and will be contingent upon AGL’s tenants consenting to the works being undertaken.

AGL has also invited tenants with any concerns over glazed doors in their homes to make contact. AGL has reached out via its own website, its “MyAcis” digital customer portal, telephone calls by its Customer Service Centre to its tenants, and by making home visits. Those actions will enable AGL to provide advice and support to its tenants, and to also bring to light any properties that might have that type of door installed, but not recorded on AGL’s database, whether as an original fixture, or because of tenants undertaking DIY and replacing doors. Depending upon the source of the door, and time of installation, AGL will either add it to a planned remediation programme or signpost the tenant to other resources in cases where the tenant has installed the door themselves during their tenancy.

Like many of AGL’s peers, the stock condition survey programme has previously focused predominantly on Decent Homes Standard compliance, and the age and condition of relevant components within a property; this would include external windows and doors but did not focus on internal glazing. Since being notified of the incident we immediately added the presence of internal glazing to our data capture requirements of the stock condition survey meaning that this information will now be gathered over the stock condition survey cycle if it is not already known or has otherwise been identified. Should further properties be identified through our stock condition survey programme over the next cycle, they will be dealt with on a case-by- case basis, as they arise.

AGL has also engaged a specialist contractor to assist with the delivery of remedial works which will be prioritised based on risk. Initial pre-works surveys are planned to commence in December 2023 with any urgent remedial works to immediately follow.

The Board of Acis Group Limited has been kept fully appraised of the position, and AGL asserts that there had been no breach of any Regulatory Standards or statutory obligations in respect of our repair and maintenance responsibilities., However, AGL took the decision to refer the issue to the Regulator of Social Housing in order to ensure that they too were fully appraised of the matter and the action that AGL has taken, and continues to take in response to it.

(Cont’d)

In addition, AGL’s Chief Executive, with the approval of the Board, contacted the National Housing Federation (NHF), asking for their support to cascade information to raise awareness amongst the social housing sector. The NHF represents its housing association members across England (who collectively provide homes for around six million people) and uses its knowledge and leadership to shape national policy and represent the views of the sector to the government and key decision makers.

AGL contacted the NHF because it recognised that the presence of this type of glazing was not unique to AGL and was in fact widespread across the UK’s housing stock, not just in social housing, but across private rented properties and privately owned residences too.

AGL have made this report to both the Regulator and the NHF to bring their attention to this incident and our response to it, and to raise awareness within the social housing sector so that AGL’s experience may enable other Registered Providers to take necessary measures in order to prevent future deaths.

AGL believes that this is a proportionate response to the matters raised by the coroner insofar as they relate to AGL’s stock.

If there is any further information that you require at this stage in relation to the reported incident or our approach to the wider issue, then please do not hesitate to telephone or email me directly.