Muhammad & Naemat Esmael
PFD Report
All Responded
Ref: 2024-0643
All 2 responses received
· Deadline: 17 Jan 2025
Coroner's Concerns (AI summary)
Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
The first MATTERS OF CONCERN is as follows: I heard evidence during the inquest that two working smoke alarms were not activated by this fire which occurred in a residential Council owned property and which led to the deaths of two individuals. I heard that this may have happened because the fire was contained in a bedroom with the door closed. I heard evidence that Welsh Government legislation (Renting Homes (Wales) Act 2016 implemented by The Renting Homes (Fitness for Human Habitation) Wales Regulations 2022) only requires rented properties to be, inter alia, fitted with two hard wired smoke alarms and that separately, sprinkler systems are only mandated in new build properties or properties undergoing alterations (Domestic Fire Safety (Wales) Measure 2011). I heard that smoke alarms in hallways only safeguard communal areas and the means of escape in a fire and that they do not provide adequate protection to mitigate against the risk to life from fires which start in individual rooms, including bedrooms. I heard that sprinkler systems are expensive for Councils and landlords to fit but that they are very successful in controlling fires and reducing fatalities from fires in properties. I also heard that hard wired smoke alarms are less expensive to fit but would still be beyond the budget of a local Council with a significant property portfolio, which is the case here. I heard that smoke alarms provide the best protection against the risk to life posed by fire in domestic and other properties. I am concerned that only mandating two smoke alarms in rented accommodation means that there is a continuing risk to life from fire in such accommodation. The second MATTERS OF CONCERN is as follows: I heard that certain items within the bedroom where the fire started, including a console unit and electrical items, were removed before they could be fully inspected in situ by the Chartered Electrical Engineer instructed to investigate the cause of the fire. I am told that the items were removed by the Crime Scene Investigators from South Wales Police in circumstances where the Fire Service had exercised its power under section 45 of the Fire and Rescue Services Act 2004 and had commenced an investigation which was aimed at determining the point of origin, cause and behaviour of the fire at . The Chartered Electrical Engineer expert told me that he was unable to provide me with any assistance on the cause of the fire because the items had been removed from the scene and because he had only been able to view photographs. It was this Expert’s opinion that it would have been preferable if the items had remained in position at the property to enable him to inspect them in situ. I am concerned that items were removed from the scene before all inspections were completed and that this may have prevented me and indeed the Fire Service investigators from determining the cause of this fire. I am concerned either that there may not be a sufficiently robust protocol in place between South Wales Police and the Fire Service on preserving a scene to ensure a full investigation takes place and / or that if there is such a protocol it may not have been followed in this instance. If coroners and investigators are unable to determine the cause of a fire because the scene has not been preserved for as long as required to ensure a full in situ investigation by all instructed investigators, then this prevents lessons from being learnt about the cause of a fire which in turn means there is a continuing risk to life.
The first MATTERS OF CONCERN is as follows: I heard evidence during the inquest that two working smoke alarms were not activated by this fire which occurred in a residential Council owned property and which led to the deaths of two individuals. I heard that this may have happened because the fire was contained in a bedroom with the door closed. I heard evidence that Welsh Government legislation (Renting Homes (Wales) Act 2016 implemented by The Renting Homes (Fitness for Human Habitation) Wales Regulations 2022) only requires rented properties to be, inter alia, fitted with two hard wired smoke alarms and that separately, sprinkler systems are only mandated in new build properties or properties undergoing alterations (Domestic Fire Safety (Wales) Measure 2011). I heard that smoke alarms in hallways only safeguard communal areas and the means of escape in a fire and that they do not provide adequate protection to mitigate against the risk to life from fires which start in individual rooms, including bedrooms. I heard that sprinkler systems are expensive for Councils and landlords to fit but that they are very successful in controlling fires and reducing fatalities from fires in properties. I also heard that hard wired smoke alarms are less expensive to fit but would still be beyond the budget of a local Council with a significant property portfolio, which is the case here. I heard that smoke alarms provide the best protection against the risk to life posed by fire in domestic and other properties. I am concerned that only mandating two smoke alarms in rented accommodation means that there is a continuing risk to life from fire in such accommodation. The second MATTERS OF CONCERN is as follows: I heard that certain items within the bedroom where the fire started, including a console unit and electrical items, were removed before they could be fully inspected in situ by the Chartered Electrical Engineer instructed to investigate the cause of the fire. I am told that the items were removed by the Crime Scene Investigators from South Wales Police in circumstances where the Fire Service had exercised its power under section 45 of the Fire and Rescue Services Act 2004 and had commenced an investigation which was aimed at determining the point of origin, cause and behaviour of the fire at . The Chartered Electrical Engineer expert told me that he was unable to provide me with any assistance on the cause of the fire because the items had been removed from the scene and because he had only been able to view photographs. It was this Expert’s opinion that it would have been preferable if the items had remained in position at the property to enable him to inspect them in situ. I am concerned that items were removed from the scene before all inspections were completed and that this may have prevented me and indeed the Fire Service investigators from determining the cause of this fire. I am concerned either that there may not be a sufficiently robust protocol in place between South Wales Police and the Fire Service on preserving a scene to ensure a full investigation takes place and / or that if there is such a protocol it may not have been followed in this instance. If coroners and investigators are unable to determine the cause of a fire because the scene has not been preserved for as long as required to ensure a full in situ investigation by all instructed investigators, then this prevents lessons from being learnt about the cause of a fire which in turn means there is a continuing risk to life.
Responses
Action Planned
Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. (AI summary)
Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. (AI summary)
View full response
Dear Ms Heaven Re: Inquest of Naemat & Muhammed Esmael vour ref: write in reply to your letter of the 22nd November 2024 and attached Regulation 28 Report to Prevent Future Deaths; my statutory response is as follows With regard to the first MATTER OF CONCERN: Mid and West Wales Fire and Rescue Service support the notion that only mandating two smoke alarms in [domestic] accommodation means that there is a continuing risk to life from fire_ The Service has previously raised this matter with the Welsh Government via the All Wales Community Risk Reduction Committee, where the Service proposed increasing smoke alar coverage to the highest standard in all new build premises in Wales and would equally support this enhancement of provision in rented accommodation. This will require a change to existing legislation andlor Building Regulations guidance which can only be undertaken the Welsh Government Action Proposed: Mid & West Wales Fire and Rescue Service will support any proposals for legislative enhancement by the Welsh Government in regard of fire alarm coverage in domestic dwellings_ Rydym m croeta ophebbob My 6mncu51252 Wo coma cortetpondondi in Wabh and Enolmh - EIN Gweledigaeth byddwy ynsteb m gxtertal fr ddeu Bcyn #cbinech waltetoan nqunr t bochamd WI reoly In your dowt kt hob uniudor ol chokt thoul doluy Rydym m croasat gettdeu Yy Gyieeg et Seesnep Wa wokoma cebhWkh end Englsh OUR VISION Mor wed i adoxldw recyced eeicholdcgc Nourmawt by ' oad
Prif Swyddog Ten Chiel Fire Oficer Gwasanaeth Tin uc Achub Canolbarth a Gorllewin Cymru Pencadlys; Heol Llwyn Pisgwydd; Headquarters, Lime Grove Avenue, Mid and West Walcs Ceerfyddin; Sir Gst; S43I ISP Caranthen; Canerthenshire; SA3I ISP Fire and Rescue Scrvice tancgcgovuk mawwfire govuk With regard to the second MATTER OF CONCERN: In fire cases involving fatalities or suspected criminality, the Police are the lead agency with primacy over the investigation. For incidents within its area, Mid & West Wales Fire and Rescue Service will often support the Police with their investigation alongside Crime Scene Investigators and forensic scientists commissioned by the Police, as in this case_ A decision to remove items for laboratory testing is undertaken by the Senior Police Officer and any evidence subsequently seized is done under the authority offered by the Police and Criminal Evidence Act (PACE): Action Proposed: do not propose to take any action in relation to this MATTER OF CONCERN as primacy for scene management in cases such as this is a Police responsibility _ Your sincerely Chief Fire Officer Aydym Gooramn ghebbath my 61cg4* S8crne9 Wa welcoma conerpondonco i Wabh end Engish - EIN GWELEDIGAETH bydomnm meteb m Oxtertol fr ddautec)n etcp ndituteard aqunlly 'obothand Mlreoty Inyour dowbs bibh hob ood1 Hodinge 0l choia withoul del y Aydymm croasa gutmdmy Gymteg ut Soesnao Wa wekome CebhWebh &d Engbah OuA VISION toox wedy bloxdu rocyded Tyourmawwlrs #elchgtbcge madh
Prif Swyddog Ten Chiel Fire Oficer Gwasanaeth Tin uc Achub Canolbarth a Gorllewin Cymru Pencadlys; Heol Llwyn Pisgwydd; Headquarters, Lime Grove Avenue, Mid and West Walcs Ceerfyddin; Sir Gst; S43I ISP Caranthen; Canerthenshire; SA3I ISP Fire and Rescue Scrvice tancgcgovuk mawwfire govuk With regard to the second MATTER OF CONCERN: In fire cases involving fatalities or suspected criminality, the Police are the lead agency with primacy over the investigation. For incidents within its area, Mid & West Wales Fire and Rescue Service will often support the Police with their investigation alongside Crime Scene Investigators and forensic scientists commissioned by the Police, as in this case_ A decision to remove items for laboratory testing is undertaken by the Senior Police Officer and any evidence subsequently seized is done under the authority offered by the Police and Criminal Evidence Act (PACE): Action Proposed: do not propose to take any action in relation to this MATTER OF CONCERN as primacy for scene management in cases such as this is a Police responsibility _ Your sincerely Chief Fire Officer Aydym Gooramn ghebbath my 61cg4* S8crne9 Wa welcoma conerpondonco i Wabh end Engish - EIN GWELEDIGAETH bydomnm meteb m Oxtertol fr ddautec)n etcp ndituteard aqunlly 'obothand Mlreoty Inyour dowbs bibh hob ood1 Hodinge 0l choia withoul del y Aydymm croasa gutmdmy Gymteg ut Soesnao Wa wekome CebhWebh &d Engbah OuA VISION toox wedy bloxdu rocyded Tyourmawwlrs #elchgtbcge madh
Noted
The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act. (AI summary)
The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act. (AI summary)
View full response
Dear Kirsten,
Thank you for your letter and Regulation 28 Report in relation to the Inquests following the sad deaths of Naemat and Muhammad Esmael.
I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.
Regarding the first Matter of Concern, Section 91 of the Renting Homes (Wales) Act 2016 (‘the 2016 Act’) places a general duty on landlords to ensure rented homes are fit for human habitation. Section 94(1) of the 2016 Act also places a duty on the Welsh Ministers to prescribe matters and circumstances to which regard must be had when determining whether a home is fit for human habitation. This is further supplemented by Section 93(3), which gives a power to the Welsh Ministers to impose requirements on landlords to prevent any matters or circumstances arising that may cause a home to be unfit.
The duty to prescribe matters and circumstances to be considered in relation to fitness, as well as the power to impose preventative requirements, are addressed in the Renting Homes (Fitness for Human Habitation) (Wales) Regulations 2022 (‘the Regulations’). The Regulations prescribe the same 29 hazards that local authorities use in conducting assessments under the statutory Housing Health and Safety Rating System, which includes the hazard of fire. The Regulations impose specific preventative requirements relating to smoke alarms, carbon monoxide alarms and the inspection and testing of the electrical installation. Regarding smoke alarms, landlords are required to ensure a hard-wired,
interconnected smoke alarm, that is in repair and in proper working order, is present on each storey of a rented dwelling. If a landlord fails to comply with this requirement, the dwelling is deemed to be unfit for human habitation and the contract-holder is not required to pay rent during the period of non-compliance. Whilst this is the minimum statutory requirement, non-statutory guidance accompanying the Regulations also states that, depending on the size of the dwelling landlords, may consider it appropriate to ensure the presence of more than one smoke alarm on each storey.
The current statutory requirements were the subject of a public consultation carried out in
2017. The consultation proposed a requirement for a smoke alarm in proper working order to be present on each storey of the dwelling on which there is a room used wholly or partly as living accommodation. As well as asking whether there should be a statutory duty on landlords to fit smoke alarms, the consultation also sought views on the type of smoke alarm to be installed and whether alarms should be interlinked. 91% or respondents to the consultation agreed that requiring landlords to fit smoke alarms was a reasonable and proportionate preventative measure. 53% of respondents considered there should be further requirements specified in the Regulations, with the majority favouring a requirement for hard-wired, inter-linked alarms. The final version of the Regulations made in January 2022 closely followed the findings of the consultation. For information, the requirement in Wales in relation to having one hard-wired, inter-linked smoke alarm on each storey of a rented dwelling, though not in every room, is similar to the requirements in England and Scotland.
Although the Welsh Government keeps all legislation under review, the 2016 Act is additionally subject to a three-year independent evaluation. This is considering all aspects of the legislation and the Phase 1 report has indicated a good awareness of the requirements in the Regulations, with landlords, agents and contract-holders all commenting on the increased provision of smoke alarms and the other preventative measures. Phase 2 of the evaluation is currently nearing completion and Phase 3, which will report in 2025, will consider the overall impact of the 2016 Act, including the Regulations. The findings of your Regulation 28 report will be considered alongside the ongoing findings from the independent evaluation and will inform a decision as to whether any changes to the current regulations are required.
Thank you for your letter and Regulation 28 Report in relation to the Inquests following the sad deaths of Naemat and Muhammad Esmael.
I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.
Regarding the first Matter of Concern, Section 91 of the Renting Homes (Wales) Act 2016 (‘the 2016 Act’) places a general duty on landlords to ensure rented homes are fit for human habitation. Section 94(1) of the 2016 Act also places a duty on the Welsh Ministers to prescribe matters and circumstances to which regard must be had when determining whether a home is fit for human habitation. This is further supplemented by Section 93(3), which gives a power to the Welsh Ministers to impose requirements on landlords to prevent any matters or circumstances arising that may cause a home to be unfit.
The duty to prescribe matters and circumstances to be considered in relation to fitness, as well as the power to impose preventative requirements, are addressed in the Renting Homes (Fitness for Human Habitation) (Wales) Regulations 2022 (‘the Regulations’). The Regulations prescribe the same 29 hazards that local authorities use in conducting assessments under the statutory Housing Health and Safety Rating System, which includes the hazard of fire. The Regulations impose specific preventative requirements relating to smoke alarms, carbon monoxide alarms and the inspection and testing of the electrical installation. Regarding smoke alarms, landlords are required to ensure a hard-wired,
interconnected smoke alarm, that is in repair and in proper working order, is present on each storey of a rented dwelling. If a landlord fails to comply with this requirement, the dwelling is deemed to be unfit for human habitation and the contract-holder is not required to pay rent during the period of non-compliance. Whilst this is the minimum statutory requirement, non-statutory guidance accompanying the Regulations also states that, depending on the size of the dwelling landlords, may consider it appropriate to ensure the presence of more than one smoke alarm on each storey.
The current statutory requirements were the subject of a public consultation carried out in
2017. The consultation proposed a requirement for a smoke alarm in proper working order to be present on each storey of the dwelling on which there is a room used wholly or partly as living accommodation. As well as asking whether there should be a statutory duty on landlords to fit smoke alarms, the consultation also sought views on the type of smoke alarm to be installed and whether alarms should be interlinked. 91% or respondents to the consultation agreed that requiring landlords to fit smoke alarms was a reasonable and proportionate preventative measure. 53% of respondents considered there should be further requirements specified in the Regulations, with the majority favouring a requirement for hard-wired, inter-linked alarms. The final version of the Regulations made in January 2022 closely followed the findings of the consultation. For information, the requirement in Wales in relation to having one hard-wired, inter-linked smoke alarm on each storey of a rented dwelling, though not in every room, is similar to the requirements in England and Scotland.
Although the Welsh Government keeps all legislation under review, the 2016 Act is additionally subject to a three-year independent evaluation. This is considering all aspects of the legislation and the Phase 1 report has indicated a good awareness of the requirements in the Regulations, with landlords, agents and contract-holders all commenting on the increased provision of smoke alarms and the other preventative measures. Phase 2 of the evaluation is currently nearing completion and Phase 3, which will report in 2025, will consider the overall impact of the 2016 Act, including the Regulations. The findings of your Regulation 28 report will be considered alongside the ongoing findings from the independent evaluation and will inform a decision as to whether any changes to the current regulations are required.
Sent To
- Welsh Government
Response Status
Linked responses
2 of 2
56-Day Deadline
17 Jan 2025
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
Circumstances of the Death
The deceased died following a house fire in a property leased to them by the Council. The property contained two working smoke alarms but they were not activated by the fire, which started in a bedroom where the door was closed.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Require fire engineer calculations for fire spread and evacuation
Grenfell Tower Inquiry
Fire risk assessment failures
Fire risk, vulnerable smokers
Require external wall information for fire services
Grenfell Tower Inquiry
Fire risk assessment failures
Train fire personnel on external wall fire risks
Grenfell Tower Inquiry
Fire risk assessment failures
Require evacuation plans for high-rise buildings
Grenfell Tower Inquiry
Fire risk assessment failures
Require compliant flat entrance doors where unsafe cladding exists
Grenfell Tower Inquiry
Fire risk assessment failures
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.