Ruth Pingree: Prevention of Future Deaths Report
Accident at Work and Health and Safety related deathsOther related deathsProduct related deaths
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Date of report: 08/04/2025
Ref: 2025-0177
Deceased name: Ruth Pingree
Coroners name: Darren Stewart
Coroners Area: Suffolk
Category: Other related deaths | Product related deaths
This report is being sent to: Ministry of Housing, Communities and Local Government | Home Office
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 [REDACTED], Deputy Prime Minister & Secretary of State for Housing, Communities and Local Government 2 [REDACTED], Secretary of State for Home Department | |
| 1 | CORONER I am Darren STEWART OBE, HM Area Coroner for the coroner area of Suffolk |
| 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 08 August 2022 I commenced an investigation touching the death of Ruth Ann PINGREE aged 42. The investigation concluded at the end of the inquest on 20 March 2025. The conclusion of the inquest was that: Narrative Conclusion – Ruth Ann PINGREE was described by her family as an amazing person. Someone who had a quality about them that drew you to her with her smile, her laugh, her heart, her vulnerability and her brilliant mind. She was a person who would make you feel loved and valued and appreciated. A one in a million. A person who was always there for her family and friends and utterly devoted to her children. On the 22nd July 2022, Mrs. Pingree, her husband and two children travelled from their home in Surrey to Suffolk where they had planned to spend time with friends holidaying in a caravan park. There were about seven families in total who travelled separately to the Happy Days Retro Vacation caravan site in Saxmundham, Suffolk. The party arrived during the evening of the 22nd July 2022. The Happy Days Retro Vacation caravan site was comprised of seven Airstream caravans arranged around various outbuildings which provided shower and toilet facilities. The caravans were made from an aluminium outer skin built on a wooden frame and steel chassis. Each caravan was named. The caravan occupied by the Pingree family was called ‘Betsy’. On the evening they arrived Mr. Pingree had briefly watched parts of an online video prepared by Happy Days Retro Vacations and which was intended to orientate guests to the caravan they would occupy and how particular aspects of the caravan operated. The video did not include a safety brief nor did the Pingree’s receive a safety brief on arrival at the Happy Days Retro Vacation site. The caravan ‘Betsy’ was fitted with a dual smoke and carbon monoxide detector and which was fixed to a wall in the kitchen area of the caravan. In addition, a fire blanket was affixed to a wall near the stove in the kitchen area and a small fire extinguisher was also located in the kitchen area. Having arrived during the evening of Friday the 22nd July 2022, the Pingree’s and their friends socialised outside near a fire pit before retiring for the evening. On Saturday the 23rd July 2022 the party enjoyed a day out travelling to Aldeburgh before returning later in the afternoon. As with the previous evening, the party socialised outside their caravans during the evening with the last person retiring at approximately 23:30 hours. As had been the case the previous evening, a fire pit had been used and several of the adult members of the group had smoked cigarettes. Adult members of the group had also consumed alcohol. A security check of the site by the owner at around 00:30 hours on the morning of the 24th July 2022 revealed nothing untoward with no sign of a fire other than a few glowing embers in the fire pit. The weather at the time had been exceptionally dry with above average (hotter) temperatures for the time of year. It was also windy on the evening of the 23rd July 2022. At some point approximately between 00:30 hours and 04:30 hours on the 24th July 2022 a smouldering fire started outside the bathroom end of the caravan ‘Betsy’ which the Pingree’s were occupying. It is not possible to say whether this was started from an ember blowing out of the fire pit or from a discarded match or cigarette butt. The fire was not started due to an electrical fault. The fire developed over a period of time engaging the external structure of the caravan. The effect of this development meant that the external aluminium cladding of the caravan heated causing the door frame of the sole caravan door to become warped and made the door inoperable; in effect jammed shut. At some time between 04:00 and 04:30 hours Mr. Pingree was woken by his son who alerted him to the fact that there was a fire. At this point there was smoke in the caravan and the fire had started to engage the inside of the bathroom end where the children had been sleeping. The smoke detector fitted in the caravan had not activated and did not sound during the fire. Mr. Pingree sought to open the caravan door which had been left unlocked, but was unable to due to the effect of the fire on the door mechanism. A friend who had been staying in the adjacent caravan and who had become aware of the fire also tried to open the door to ‘Betsy’ unsuccessfully. Turning to the right and away from the door and facing his family who were in the kitchen area of the caravan, Mr. Pingree realised that quick action was required in order to escape the caravan. The fire was fully engaging the bathroom end of the caravan at this point and the entire space had quickly become full of acrid dark smoke. Mr. Pingree then used his body to force open the window above the sink in the kitchen area and climbed outside. He was followed by his two children. Mrs. Pingree had remained to assist the children in their escape. Her actions in doing so meant that the children were able to escape the burning caravan. Sadly Mrs. Pingree was not able to escape the caravan and shortly after the second child escaped, the caravan became engulfed in fire and smoke. Desperate efforts to extinguish the fire by those present were unsuccessful and it was not until the Fire Service arrived at 04:45 hours that the fire was finally extinguished. By this point Mrs. Pingree had sadly perished in the fire. Had the fire alarm functioned it is likely that this would have been before the Pingree’s son had raised the alarm. It is not possible however to say if this would have meant Mrs. Pingree would have escaped the caravan before being overcome by the fire fumes. A postmortem examination of Mrs. Pingree’s body established that her medical cause of death was due to the inhalation of fire fumes. Investigation of the cause of the fire established that the source of the fire was not due to an electrical fault, but rather either an ember blowing from a nearby fire pit or a discarded cigarette/match. This caused a smouldering fire to develop over a period of time outside the caravan and which then engulfed the caravan. Ruth Ann PINGREE died as a result of the effects of a fire in a caravan she was holidaying in and which started due to accidental causes. The medical cause of death was confirmed as: 1a. Inhalation of fire fumes |
| 4 | CIRCUMSTANCES OF THE DEATH See Narrative Conclusion above |
| 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 Inquest heard evidence concerning the operation of the Regulatory Reform Fire Safety Order 2005 (FSO). In assessing the actions by owners/proprietors of businesses such as Happy Days Retro Vacations for compliance with the FSO, there is a general test of suitability and sufficiency applied in relation to measures undertaken by the relevant responsible person/entity (proprietors) to comply with the FSO. This does not require that the proprietors: . keep any written records; . set a specific interval of maintenance inspections; or . provide any signage or safety notices in caravans indicating escape routes or actions in case of emergency. There would not appear to be any set guidance or format for the conduct of a risk assessment, what this must cover nor how often they should be conducted. Proprietors, who under the FSO, are responsible for carrying out risk assessments are provided within the FSO with a general set of requirements that need to then be considered as to applicability to any given activity. The means to understand and interpret the requirement is reliant upon the research ability of those charged with undertaking the risk assessment. Guidance documents such as the Paying Guest Guide do exist and outline best practice steps, however these are not included in the FSO as minimum standards a responsible person/entity is required to take. The potential for short cuts and misunderstandings are substantial. This is within a framework of assurance and enforcement that would appear to be ad hoc. This is in the context of businesses providing accommodation to the public on a paid basis. There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this. |
| 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 June 02, 2025. 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 [REDACTED] (Husband) (via legal representatives) [REDACTED] (Mother) [REDACTED] (Sister) Happy Days Retro Vacations Ltd. (via legal representatives) Suffolk Fire and Rescue Service (via legal representatives) East Suffolk Council (via legal representatives) I have also sent it to The National Fire Chiefs Council who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 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 | Dated: 08/04/2025 Darren STEWART OBE HM Area Coroner for Suffolk |