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recurance

George Hines

27 Oct 2015 · Coroner Peter Harrowing · Avon

The coroner's concerns

  1. 1. pull-cord not connected to ceiling switch

    “The pull-cord in the bedroom of the deceased was found by the Fire Investigation Officer not to be connected to the ceiling switch. Notwithstanding the regular visits by the HSA this defect was not noted and no corrective action had been taken. No evidence of a regular planned preventative maintenance programme was given to the inquest with regard to ensuring all pull-cords were working and in good order. The Council should implement a regular inspection and maintenance programme for the alarm”
  2. 2. smoke detector not regularly inspected

    “The Council should implement a regular programme of its own of inspection, testing and maintenance of the smoke detector”
  3. 3. smoke detector only alarms in individual flat

    “The smoke detector did not alert other residents to the fire”
  4. 4. instructions to pull cord may give false sense of security

    “The Council should revise its instructions to residents in the event of fire generally and specifically that they are instructed to dial 999 first before taking any other action”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error