Letter from the Assistant Coroner for the Eastern Area of Greater London

The LGA has received a regulation 28 report to prevent future deaths from Dr Shirley Radcliffe, Assistant Coroner for the area of Eastern Area of Greater London, in relation to the deaths of two residents in a fire in a maisonette in London on 25 January 2017.


This is relevant to:

  1. councils that are local housing authorities
  2. councils that are landlords.

The coroner found that:

‘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’

and that

‘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’

but that stakeholders are not sufficiently aware of the risks that this poses.

Registered Providers and private sector landlords need to ensure they have undertaken a fire safety risk assessment for their flats, where these flats require an alternative means of escape from any storey level, such as escape via a linking balcony. Their assessment, and any remedial works, should follow the advice in the LGA Fire Safety in Purpose-Built Block of Flats guide, specifically Section 56.

Housing Authorities should specifically consider this issue under the Housing Health and Safety Rating System.

The National Fire Chiefs Council is writing to fire and rescue services about the importance of the LGA guidance and the recommendations outlined within the coroner’s findings. Local authorities may find it helpful to speak to their fire and rescue service if they have any queries about this matter and to read the Specialised Housing Guidance on the Higher Risk Accommodation page of the National Fire Chief Council’s website.

The circumstances of the death was that a fire occurred at the home address of the deceased on 25 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 two deceased were unable to escape to safety before being overcome with fire fumes.

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:

  1. Undermining of the originally provided fire safety measures i.e. missing kitchen door
  2. 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
  3. 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 neighbour's flat.