Dorina Zangari

PFD Report Historic (No Identified Response) Ref: 2018-0403-wp26469
Date of Report 21 December 2018
Coroner Shirley Radcliffe
Coroner Area London (East)
Response Deadline est. 15 February 2019
No published response · Over 2 years old
Response Status
Responses 0 of 1
56-Day Deadline 15 Feb 2019
Over 2 years old — no identified published response
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
1. The maisonette in which Dorina Zangari and Michaela Lazar lived was let for use as a single private dwelling. As it happened, it was being used as a House in Multiple Occupation, but the fire safety issues of concern to LFB relate to any maisonette used as a single family dwelling. The lack of early detection and warning of fire (i.e. the provision of smoke alarms) and a protected means of escape from the upper floor of the maisonette (which was at too high a level for escape by windows) contributed to the occupants being unable to escape from the fire.

The problem is threefold:-

i) Undermining of the originally provided fire safety measures i.e. missing kitchen door ii) Absence of functioning fire detection and warning in the hall or landing, which was not required at the time of construction of the block of flats but, at the time of the fire, was a statutory requirement both for flats in single family occupation and multiple occupation; and iii) The design of the alternative means of escape, which comprised the balcony on the upper level of the maisonette, shared with the next door maisonette. This was acceptable at the time of construction but this is not acceptable today (without additional measures such as smoke alarms in every room) as this will involve breaking in to a neighbours flat.

There are many thousands of these types of maisonette across the country which have not been upgraded using options in line with best practice guidance (see below) and this is leaving people at a significant risk of death or injury from fire.

The recommendations below are relevant to all existing single family maisonettes additional measures might be necessary if the maisonette is in multiple occupation). The adoption of the guidance referenced below would have given the occupants a greater chance of being alerted to the fire at an earlier stage by the fire detection system and would have afforded safe means of escape from the upper floor of the maisonette.

2. The Local Government Association Fire safety in purpose-built blocks of flats guidance

Flats with more than one storey, with a floor at more than 4.5m above ground level

56.31 The internal means of escape from flats with more than one storey (eg maisonettes and cross-over flats), with a floor at more than 4.5m above ground level, provide additional issues to those encountered in flats on one level. Nevertheless, the basic approaches of providing either a protected exit route or an alternative exit remain the same.

56.32 Current benchmark design guidance recommends four approaches to the planning of means of escape from these flats:

I. provide an alternative exit from each habitable room that is not on the entrance level
Report Sections
Investigation and Inquest
On the 2nd February 2016 an investigation was commenced into the death of Ms Mihaela Lazar and Ms Dorina Zangari. The investigation concluded at the end of the Inquest on the 20th November 2018.

The conclusion was death accidental death due to inhalation of fire fumes
Circumstances of the Death
The circumstances of the death was that a fire occurred at the home address of the deceased on 25th January 2017. The fire probably started from clothing overlying a heater on the lower level of the premises. This caused dense smoke to spread through the maisonette and the 2 deceased were unable to escape to safety before being overcome with fire fumes.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.