Jacqueline Joseph

PFD Report All Responded Ref: 2026-0102
Date of Report 19 February 2026
Coroner Bina Patel
Response Deadline est. 16 April 2026
All 1 response received · Deadline: 16 Apr 2026
Coroner's Concerns (AI summary)
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
View full coroner's concerns
The premises is a housing association property and Squared (Luton Community Housing Ltd) is the organisation responsible for this property and various other housing association properties and the evidence heard at the inquest was that the premises had two incorrectly installed battery-operated smoke alarms.
Responses
Squared
15 Apr 2026
Noted
(AI summary)
View full response
Dear Ms Patel

RE: Response to Regulation 28 Report Jacqueline Joseph

Thank you for your Regulation 28 Report issued following the inquest into the tragic death of Jacqueline Joseph. We extend our sincere condolences to the family and all those affected. We write with the full authority of Squared’s Board.

We recognise and acknowledge the seriousness of the concerns you have raised. Customer safety is Squared’s most important priority. We are committed to ensuring that all reasonable steps are taken to promote fire safety in the homes we let.

For completeness, please note that liability is not accepted in this particular case. However, this will not affect our determination to learn from this tragedy.

Our approach to vulnerable customers

Squared aims to identify and monitor the needs of vulnerable customers on an ongoing basis and particularly at key stages of their tenancy journey. This includes during tenancy sign‑up and through tenancy audit inspections. In addition, any further reports or concerns arising from contractors (internal and external) during compliance visits or routine maintenance works, are fed back to the Homes Team to address where appropriate.

If adaptations or any identified risks are highlighted, we work with Luton Borough Council and the assigned Occupational Therapist to best action the customer’s need. Frontline team members are trained to recognise and report all concerns, ensuring timely referrals to the Homes Team or escalation to the Safeguarding Lead.

With this in mind, we maintain strong working relationships with social services and other partner agencies. This means that we can signpost customers to appropriate external support to aid them in seeking the assistance they need. We are committed to keeping these practices under regular review to ensure that no safeguarding opportunity is missed.

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Fire safety

Policies have, for some time, been in place to ensure that homes let by Squared are to a high standard. Whilst these policies pre-dated the tragic death of Ms Joseph, it was only right for us to have reassessed them, in light of the tragedy. We detail this further below.

Squared’s approach to fire safety is not limited to its strict legal obligations. The late Ms Joseph’s tenancy of (”the Property”) began in November
1996. Whilst this placed the tenancy outside of the scope of the Smoke and Carbon Monoxide Alarm (England) Regulations 2015, smoke alarms were nonetheless fitted to each storey of the property as though those regulations had applied.

We were very concerned to note your reference to evidence of “incorrectly installed battery- operated smoke alarms”. As detailed further in this letter, Squared will work with both Bedfordshire Fire and Rescue Service and Luton Borough Council to ensure that any defect or potential defect is fully understood, rectified and learned from.

Review

As you would expect, an internal review has taken place following the receipt of your report.

This included an examination of our processes to include strengthening/enhancing:

• Our tenancy audit checklist to ensure that smoke and carbon monoxide alarms are tested and recorded appropriately.
• Our data held on customers with vulnerabilities to ensure it is accurate, current and supports fire safety risk management.
• Our gas safety certification procedures to provide increased oversight.
• Our communication practices relating to smoke and carbon monoxide (CO) alarm compliance.

Squared remains committed to ensuring that all properties meet or exceed statutory safety requirements and that our customers are properly supported to understand and fulfil their responsibilities regarding alarm testing and reporting.

Actions Taken or already in place

Measures are being implemented across our services to ensure best practice.

Actions Taken or already in place Current Status We continue to test smoke and CO alarms during voids (periods when homes are unoccupied), annual gas safety checks and during tenancy audits. Repairs or replacements are carried out as necessary. In place and ongoing For the maximum avoidance of any doubt, a comprehensive smoke and CO alarm audit has been completed across all homes let by Squared (whether we own the freehold or not) to confirm that all devices are fitted in accordance with Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022 and are in good working order. All issues identified are being surveyed and any confirmed failures are being remedied without delay through emergency repairs. Audit completed Surveys in progress with target completion date of 30th May 2026

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We have written to all customers to reinforce the importance of smoke and carbon monoxide alarm safety. While customers are ordinarily encouraged to test alarms, report faults and replace batteries (where this is their responsibility), we recognise that some customers will require practical support or adjusted arrangements, and we will be reviewing how this is identified and provided consistently. Customer communication completed 10th March 2026 To be repeated 6 monthly Review 1st May 2026

Tenancy audits prioritised for known vulnerable, relevant customers to ensure data is accurate and up to date. Start date 13th April 2026 Target date for completion 12th June 2026 We have enhanced our customer sign-up process so that, not only are alarms tested at the start of the tenancy, but the customers are asked to confirm that they are satisfied they are in working order. Completed 3rd March 2026 and ongoing We have circulated a focused bulletin to frontline team members, reiterating their critical responsibility in maintaining customer safety by ensuring smoke, heat, and CO alarms are correctly managed. Completed 16th March 2026 To be repeated quarterly

We contacted the Beds Fire and Rescue Service to request their feedback on our draft response, ensuring it is accurate, comprehensive, and that no fire‑safety considerations have been overlooked. They directed us to engage with Luton Borough Council’s Private Sector Housing team, which we have done, and we are now awaiting their response. Contacted Beds Fire and Rescue Service 9th March 2026 Contacted Luton Borough Council 11th March 2026 We will proactively implement person centred fire risk assessments and put Personal Emergency Evacuation Plans (PEEPs) in place for customers whose mobility, disability, health or support needs may affect fire safety or their ability to evacuate safely. We will identify customers with needs that may impact fire safety or evacuation to carry out a person centred fire risk assessments and PEEPs where appropriate, prioritising those with known and existing vulnerabilities. In parallel, we will review how customers who are housebound, immobile, or otherwise have relevant support needs are identified, and how they are considered for referral to partner agencies for additional fire safety support where appropriate. Start date 13th April 2026 Target date for completion 17th July 2026 and then ongoing

Actions Proposed and Ongoing Improvements

To further strengthen our approach and reduce future risk, we are implementing the following measures:

Actions Proposed Status In addition to our statutory obligations, we have implemented a planned rolling programme to replace smoke, heat and carbon monoxide alarms upon reaching the manufacturer-recommended 10-year lifespan. This Start date 23rd April 2026 and rolling

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approach ensures that all alarms remain compliant with the LD2 standard. For properties where we do not hold the freehold (leased properties), we will undertake surveys to ensure that all alarms are compliant and are replaced as they approach the end of their service life. Start date 20th April 2026 Target completion date 29th May 2026 Future monthly Leadership and quarterly Board reports will now include smoke, heat and CO alarms updates. Leadership Team Meeting 30th April 2026 and ongoing Board meeting 27th May 2026 and ongoing We plan to include smoke, heat, and CO alarm replacement updates as an agenda item at our next Customer Engagement Group meeting, to ensure ongoing customer involvement and feedback. Customer Engagement Group meeting 28th April 2026 Consideration to be given to promoting smoke-free homes as part of our wider approach to improving fire safety and customer wellbeing with our Customer Engagement Group Customer Engagement Group meeting 28th April 2026 Leadership meeting 30th April 2026 To support robust implementation and provide independent assurance, we are considering commissioning an internal audit or other independent review of our fire safety controls. Scoping and timings to be confirmed by 17th July 2026

These actions are designed to strengthen our compliance framework, maximise oversight, and ensure that both team members and tenants remain fully aware of their responsibilities.

We repeat that Squared takes the matters raised in your report extremely seriously. We are committed to learning all we can from this incident. The actions outlined above reflect our determination to maximise safety standards, our communication with customers, and the extent to which we work collaboratively with partner agencies.

Should you require any further information or clarification, we will be pleased to provide it.
Sent To
  • Luton Community Housing Ltd
Response Status
Linked responses 1 of 1
56-Day Deadline 16 Apr 2026
All responses received
About PFD responses

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

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 16 June 2025, I commenced an investigation into the death of Jacqueline JOSEPH aged 60, who died on the 15 June 2025. The investigation concluded at the end of the inquest on 13 November 2025. The medical cause of death was: 1a Direct Thermal Injury 1b Fire Exposure

The conclusion of the inquest was: Accident.
Circumstances of the Death
Jacqueline JOSEPH occupies 2 Ellenhall Close, Luton, Bedfordshire, a housing association property. She was a known smoker, had a stroke approximately 10 years ago and limited mobility, as a result she had care and support needs. She was supported by carers who visited her four times a day. The premises had one battery-operated smoke alarm positioned on a vertical wall on the first-floor landing and one battery-operated smoke alarm position on top of the cooker grill in the ground floor kitchen. No careline provision was installed at the premises. Bedfordshire Fire Rescue Service had never visited the premises before the 999 call on the 15 June 2025 as they had never received a Home Fire Safety Visit Referral from authorities or family.

On the 15 June 2025, she was found in an armchair of the living room on the ground floor of the premises. She was confirmed deceased on this day having been discovered seated in the armchair subjected to flame and heat which had sustained itself from her lap, unable to extinguish the fire or self-rescue, Jacqueline Joseph succumbed to the fire and heat. Her daughter immediately alerted Bedfordshire Fire Service having observed her mother on fire via a camera (CCTV) installed in her lounge by the family, and their response time was prompt. In the fire investigator’s opinion, aside from pre-prepared preventative measures such as a fire suppression system, nothing further could have been done to save Jacqueline Joseph on 15th June 2025 once the fire had fully developed. Luton Safeguarding Adults Board (LSAB) since the date of this incident are undertaking work with partner agencies to ensure residents who are home, immobile or housebound with specific support needs have received referrals for a Home Fire Safety Visit where applicable.
Copies Sent To
Bedfordshire Fire Service Luton Safeguarding Adults Board
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.