Trevor Ridd
16 Jun 2026 · Coroner Paramdeep Bains · Birmingham and Solihull
The coroner's concerns
1. sprinkler system generating two signals within seconds
“It is not clear why the sprinkler system generated two signals (one 'fault' and one 'fire') within seconds of one another and what the procedure was for handling this.”
2. operator failing to raise 999 call on dual signals
“It remains unclear as to why the individual operator treated both signals as being part of the same incident and failed to raise a 999 call; it is not clear how a fault notification works alongside a fire notification.”
3. lack of training on handling rapid dual signals
“It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr [name redacted] property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed?”
4. incorrect signal order causing confusion
“The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified.”
5. lack of sprinkler system testing and maintenance
“There is no evidence of regular testing and maintenance of the sprinkler system.”
6. lack of post-incident briefing on dual signals
“It is not clear what individual operators have been 'briefed' on post-incident with regards to situations where two notification signals are received in quick succession from the same property.”
7. lack of communication on verifying secondary signal wording
“It is not clear what communications have been issued to staff to reinforce the requirement to verify wording of any secondary signals, nor is it clear how staff are to verify the wording of secondary signals.”