Recurring concern

Inadequate controls for carbon monoxide exposure

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First reported 18 Oct 2013•Latest report 31 Mar 2026

Definition

What this concern includes

Includes failures of controls specifically intended to prevent, detect, warn about or respond to carbon monoxide exposure, including monitoring or warning devices, detection requirements, guidance on sources and movement of carbon monoxide, and hazard controls for aircraft, residential or other occupied settings.

Not included

  • Excludes generic fire, gas, ventilation, heating, aircraft-maintenance or accommodation deficiencies where carbon monoxide exposure is not the material safety hazard.
  • Excludes clinical treatment or investigation after carbon monoxide poisoning has been identified when the exposure-prevention or detection control itself was adequate.
  • Excludes other toxic gases, organophosphate exposure and general product or premises hazards without a carbon monoxide component.
  • Excludes generic training or communication deficiencies unless they directly concern recognising, preventing or responding to carbon monoxide exposure.
Reports
9

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

ABTA Ltd1
All-Party Parliamentary Carbon Monoxide Group1
Borough Housing Limited1
Churchers Solicitors LLP1
Civil Aviation Authority1
Department for Digital, Culture, Media and Sport1
Department of Energy & Climate Change1
Department of Trade and Industry1
Executor of the estate1
Foreign, Commonwealth & Development Office1
Greater Manchester Fire and Rescue Service1
GS Halls Limited1
Health and Safety Executive1
KK Security & FM Ltd1
London Borough of Wandsworth1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Jack Saunders · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack Saunders was found deceased in his tent at Waddecar Scout Camp on 3 April 2017, after arriving alone on 29 March 2017. The cause of death was carbon monoxide poisoning from a Landman outdoor heater that generated high levels of carbon monoxide inside the tent. The principal concerns were the absence of available equipment instructions, inadequate delivery of carbon monoxide safety training to local trainers, and Jack’s exposure to adult leaders using fuel-burning equipment in tents.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure carbon monoxide poisoning risk training reaches trainers within individual troops

    Wider context from the report

    “(2) That on the finding of the jury, whilst knowledge around the risks of carbon monoxide poisoning was known and training had been prepared nationally, this had not reached the trainers within individual troops. ”

    Source location

    Jack Saunders · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver regular, role-specific, year-round carbon monoxide safety communications supported by external partnership resources.

    Verbatim wording from the response

    “Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities.”

    Source location

    Response from the Scouts Association
    Page 4 · response
    Published 8 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a safety alert and learning notice requiring local leaders to reaffirm carbon monoxide knowledge, confirm safe practice and review displayed safety information.

    Verbatim wording from the response

    “We will keep improving by Issuing a specific safety alert and learning notice by 26 June 2026 to bring this PFD and TSA’s response to the attention of all volunteers. The notice will require lead volunteers and board members of our more than 7000 Scout charities across Groups, Districts and Counties to:”

    Source location

    Response from the Scouts Association
    Page 8 · response
    Published 8 April 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue strengthening targeted support and interventions so leaders understand and act on carbon monoxide risks.

    Verbatim wording from the response

    “Continuing to strengthen how we target support and interventions, so that the CO risk is understood by leaders and acted upon.”

    Source location

    Response from the Scouts Association
    Page 10 · response
    Published 8 April 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    District or County Lead Volunteers or nominees are responsible for approving nights away and reviewing associated risk assessments, including carbon monoxide risks.

    Verbatim wording from the response

    “• The relevant District or County Lead Volunteer or nominee is responsible for approving nights away for groups of adults, where each individual is aged 18 and over. This includes reviewing the risk assessment, which contributes to ensuring that CO risk knowledge is present in individual groups. This is detailed in our Policy, Organisation and Rules document (POR) - rule number 9a.1.3.2.”

    Source location

    Response from the Scouts Association
    Page 7 · response
    Published 8 April 2026

    Open published response
  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Thomas Oliver HILL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Oliver HILL died on 28 October 2015 after inhaling a fatal quantity of carbon monoxide from a flue-less liquefied petroleum gas cabinet heater while preparing for a bath. The report identified concerns about the heater being used in an undersized room, the absence of a visible external warning label, and it not being obvious to all users that adequate room dimensions were required for safe use.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Operation of flue-less liquified petroleum gas cabinet heaters in rooms too small to prevent carbon monoxide build-up

    Wider context from the report

    “The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle. There was an absence of a visible warning label on the outside of the heater. It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension. The risk applies particularly so in the case of rented cottages and similar premises such as ████████ ”

    Source location

    Thomas Oliver HILL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Peter John CAMP · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter John CAMP was found deceased in his bedroom after police attended his address following a concern for his welfare. Post-mortem examination found elevated carboxyhaemoglobin levels indicative of carbon monoxide toxicity; the source had not yet been ascertained, with faulty heating or cooking apparatus or inadequate ventilation identified as likely possibilities, and a continuing risk to life was noted at the property.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuing risk to life from carbon monoxide at the property

    Wider context from the report

    “The deceased has been found at post-mortem examination to have elevated levels of blood carboxyhaemoglobin (COHb). This elevated level is indicative of carbon monoxide toxicity. The deceased was exposed to carbon monoxide at 2, The Haven, Gosport, Hampshire. Carbon monoxide toxicity can lead to death. There is a continuing risk to life caused by the present circumstances at 2, The Haven, Gosport, Hampshire. The source of the carbon monoxide has not yet been ascertained but is likely to be associated with faulty heating/cooking apparatus or ventilation. ”

    Source location

    Peter John CAMP · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. Inner West London

    AI-generated summary

    Saima Usman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Saima Usman, aged 44, was found deceased at her home following a fire on 8 July 2021. The fire did not contribute to her death; the recorded conclusion was an accidental drug-related death. The substantive concern was that people living in privately rented accommodation in Wandsworth may be at greater risk because the borough did not have a registered landlord scheme requiring smoke and carbon monoxide detectors.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a registered landlord scheme requiring installation of smoke and carbon monoxide detectors

    Wider context from the report

    “That those living in privately rented accommodation within the London Borough of Wandsworth are at greater risk of death from exposure to fire or CO, as it does not currently have registered landlord scheme through which in order to be registered smoke and CO detectors would have to be installed. ”

    Source location

    Saima Usman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Buckinghamshire

    AI-generated summary

    Jaspal Singh BAHRA and 3 others · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jaspal Singh Bahra, Saavan Singh Mundae, Michael Leonard Green and Thanh Trung Nguyen died at the scene after the aircraft they were flying collided over Wilderness Wood in Buckinghamshire on 17 November 2017. The report raised concerns about reliance on the “See and Avoid” procedure in unregulated airspace without universal electronic proximity warning or collision-avoidance devices, and about the lack of mandatory carbon monoxide monitors or warning devices in light aircraft.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Risk of Carbon Monoxide exposure in light aircraft from undetected exhaust or heating-system defects

    Wider context from the report

    “(2) Although it could not be demonstrated that exposure to Carbon Monoxide prior to or during flight played a part in the implementation of “See and Avoid” or the collision, evidence demonstrated that it is not mandatory for light aircraft such as were involved in this collision to carry any Carbon Monoxide monitors or warning devices, notwithstanding their potential availability. Given the regular service requirements for such craft and the possible limitations in identifying airline cracks or hidden defects in aircraft exhaust and heating systems, there remains a risk that pilots and passengers may be exposed to Carbon Monoxide in such craft which might directly put them at risk of death or might put the craft at risk of collision or accident carrying with that the inherent risk of death. ”

    Source location

    Jaspal Singh BAHRA and 3 others · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of mandatory carriage of Carbon Monoxide monitors or warning devices in light aircraft

    Wider context from the report

    “(2) Although it could not be demonstrated that exposure to Carbon Monoxide prior to or during flight played a part in the implementation of “See and Avoid” or the collision, evidence demonstrated that it is not mandatory for light aircraft such as were involved in this collision to carry any Carbon Monoxide monitors or warning devices, notwithstanding their potential availability. Given the regular service requirements for such craft and the possible limitations in identifying airline cracks or hidden defects in aircraft exhaust and heating systems, there remains a risk that pilots and passengers may be exposed to Carbon Monoxide in such craft which might directly put them at risk of death or might put the craft at risk of collision or accident carrying with that the inherent risk of death. ”

    Source location

    Jaspal Singh BAHRA and 3 others · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish and maintain guidance on carbon monoxide contamination, including maintenance expectations, inspection importance and testing methods.

    Verbatim wording from the response

    “CAA Publication (CAP) 562 ‘Civil Aircraft Airworthiness Information and Procedures’”

    Source location

    2019-0160-Response-by-Civil-Aviation-Authority
    Page 5 · response
    Published 2 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consult the AOPA Maintenance Working Group, consider the merits of a carbon monoxide Safety Notice and decide whether to publish it.

    Verbatim wording from the response

    “The Regulation 28 report to prevent future deaths has provided an opportunity to review available material on CO contamination avoidance. Notwithstanding the measures already in place and those expected in the near future, the CAA will consider the merits of an additional information on best practice CO contamination avoidance, in a ‘Safety Notice’ publication. To this end, the CAA will consult with members of the relevant stakeholder forum, the AOPA Maintenance Working Group, in making this decision by the end of the third quarter of 2019. If a decision be made to publish a Safety Notice, this is expected to take place by the end of 2019.”

    Source location

    2019-0160-Response-by-Civil-Aviation-Authority
    Page 6 · response
    Published 2 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Changes to aircraft design requirements, including CO detector requirements, would need to be made by EASA.

    Verbatim wording from the response

    “The European Aviation Safety Agency (EASA) has oversight of the design of the aircraft involved in this accident. EASA promulgates design requirements (‘codes’) CS-23 for ‘Small Light Aeroplanes’ and CS-VLR for ‘Very Light Rotorcraft’, which contain specific requirements on cockpit contamination preventative measures. Any change to those requirements would need to be brought about by EASA. The codes address the required levels of ventilation, the maximum acceptable CO content in the cockpit and the design of heating systems (notably exhaust-related heat exchangers) with a view to preventing CO contamination in the cockpit. The codes do not require CO detectors to be fitted as part of the design. Similar design requirements exist in the United States, which is the primary source of general aviation aircraft types.”

    Source location

    2019-0160-Response-by-Civil-Aviation-Authority
    Page 4 · response
    Published 2 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CO detectors are not mandated because aircraft certification requirements are considered sufficient to minimise contamination risk; installation remains at pilot or owner discretion.

    Verbatim wording from the response

    “CO detectors may be fitted to UK-registered aircraft as ‘standard changes’ under the provisions of CS-STAN (for EASA aircraft) and CAP 1419 (for non-EASA aircraft). This removes the need for direct authority involvement, allowing equipment to be installed without the associated time and costs.”

    Source location

    2019-0160-Response-by-Civil-Aviation-Authority
    Page 5 · response
    Published 2 August 2019

    Open published response
  6. Manchester North

    AI-generated summary

    John Eric Graham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Eric Graham was found dead at his home on 26 February 2018. Although carbon monoxide was initially considered and later excluded from the cause of death, the report raised concern that carbon monoxide detectors were not routinely installed in homes rented by Rochdale Borough Housing Limited, creating a risk of future deaths if unremedied.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of routine carbon monoxide detector installation in rented residential accommodation

    Wider context from the report

    “Carbon monoxide detectors are not routinely installed in residential accommodation rented by Rochdale Borough Housing Limited which, if unremedied, creates a risk of future deaths. ”

    Source location

    John Eric Graham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue monitoring the Government review of carbon monoxide alarm requirements.

    Verbatim wording from the response

    “Rochdale Boroughwide Housing will continue to monitor the outcome of the current review and any recommendations which follow will be considered for implementation.”

    Source location

    2018-0348-Response-by-Rochdale-Boroughwide-Housing-Limited
    Page 2 · response
    Published 12 April 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider implementing recommendations arising from the Government review.

    Verbatim wording from the response

    “Rochdale Boroughwide Housing will continue to monitor the outcome of the current review and any recommendations which follow will be considered for implementation.”

    Source location

    2018-0348-Response-by-Rochdale-Boroughwide-Housing-Limited
    Page 2 · response
    Published 12 April 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A wholesale carbon monoxide detector installation programme cannot prudently be considered until the Government review establishes detailed requirements.

    Verbatim wording from the response

    “Until the outcome of that review is known it would not be prudent to consider a wholesale installation programme in the absence of the detailed requirements that such a recommendation would bring. For example, the most recent changes in Scotland will require smoke and carbon monoxide detectors in specific locations and of specific types. They will also need to be hard wired when those regulations come into force in Scotland in February 2021.”

    Source location

    2018-0348-Response-by-Rochdale-Boroughwide-Housing-Limited
    Page 1 · response
    Published 12 April 2019

    Open published response
  7. Manchester West

    AI-generated summary

    Javaid Iqbal · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Javaid Iqbal, who was working alone as a security guard at a construction site, died after lighting charcoal in a wheelbarrow inside a portacabin when the generator failed and left him without heat or light. The concerns included inadequate response to his reports, insufficient cold-weather clothing, lack of clear instructions for lone working, and the need for written instructions and training concerning welfare, safe temperatures, clothing, and leaving the site.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide a prominent warning about the risk of fatal carbon monoxide poisoning from indoor use

    Wider context from the report

    “(1) The packaging of the charcoal provides instructions which indicate it should not be used indoors. The warning is not given much prominence and does not draw attention to the risk of death from carbon monoxide poisoning if used indoors. ”

    Source location

    Javaid Iqbal · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. West Yorkshire (East)

    AI-generated summary

    Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide carbon monoxide detectors in accommodation with individual gas appliances

    Wider context from the report

    “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises. That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto. ”

    Source location

    Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of common minimum gas-installation and carbon-monoxide safety standards for holiday premises

    Wider context from the report

    “8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises. That the Government should do its utmost to encourage and promote through legislation and enforcement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto. ”

    Source location

    Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  9. Manchester City

    AI-generated summary

    ELIZABETH AURORA KERR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elizabeth Aurora Kerr died after carbon monoxide from a malfunctioning basement boiler entered the residential flat where she lived, and she was found unconscious several hours after the Fire Service had attended the building. The report identified concerns about the movement and detection of carbon monoxide in buildings, the absence and use of carbon monoxide alarms and gas safety controls, and Fire and Rescue Service equipment, guidance and responses.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances

    Wider context from the report

    “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms. GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement

    Wider context from the report

    “3. The Role of Fire and Rescue Services in Carbon Monoxide Safety: The Fire and Rescue Services currently have no statutory role in Carbon Monoxide safety, regulation and enforcement. This could be reviewed and considered by the Department for Communities and Local Government. It is appreciated that this is far from straight forward and wider issues would need to be taken into account. For example Fire and Rescue Services have no statutory role in other gases or substances which can cause death. This may require a more detailed analysis and assessment of issues and complications which may then come to light. In the absence of a statutory role, and possibly through the Chief Fire Officers Association “Blue Watch” initiative, Fire and Rescue Services could be encouraged to voluntarily engage in local and national Carbon Monoxide campaigns. Such campaigns may benefit from closer working at a local level with relevant CO charities and at a national level between the Gas Safety Trust, the Gas Safe Charity and the Chief Fire Officers Association. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of suitable training in the operation of carbon monoxide detection equipment

    Wider context from the report

    “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms. GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings

    Wider context from the report

    “2. Guidance on the potential movement of CO within a building: There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a duty to warn other occupants to install carbon monoxide alarms

    Wider context from the report

    “8. The Chief Fire Officers Association “Blue Watch Initiative” This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents. http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of required audit trails of fuel-supplier carbon monoxide safety steps

    Wider context from the report

    “5. Enforcement and Information: There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of required specific carbon monoxide safety information from fuel suppliers

    Wider context from the report

    “5. Enforcement and Information: There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give. ”

    Source location

    ELIZABETH AURORA KERR · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report
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Data last updated 7 September 2026