Jacqueline JOSEPH · Prevention of Future Deaths report

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.

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.

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.