Jacqueline Joseph: Prevention of future deaths report
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Date of report: 19/02/2026
Ref: 2026-0102
Deceased name: Jacqueline Joseph
Coroner name: Bina Patel
Coroner Area: Bedfordshire and Luton
Category: Other related deaths
This report is being sent to: Luton Community Housing Ltd
 REGULATION 28 REPORT TO PREVENT DEATHS | |
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| THIS REPORT IS BEING SENT TO: 1 Squared (Luton Community Housing Ltd) Unit 2B Enterprise Way Bramingham Business Centre Luton | |
| 1 | CORONER I am Bina PATEL, Area Coroner for the coroner area of Bedfordshire and Luton Coroner Service |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST 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. |
| 4 | CIRCUMSTANCES OF THE DEATH 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. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 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. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 16, 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Jacqueline Joseph’s Family Luton Borough Council Blue Bird Care I have also sent it to Bedfordshire Fire Service Luton Safeguarding Adults Board I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
| 9 | 19 February 2026 Bina PATEL Area Coroner for Bedfordshire and Luton Coroner Service |